ABC of Counselling Adolescents Towards Behaviour Change (2 Edition)
ABC of Counselling Adolescents Towards Behaviour Change (2nd Edition) HEALTHY YOUNG PEOPLE: BETTER FUTURE ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 1 Table of Contents Acknowledgement......................................................................................................................................... ii Foreword ...................................................................................................................................................... iii List of Acronyms and Abbreviations ............................................................................................................. iv CHAPTER 1: UNDERSTANDING ADOLESCENTS AND ADOLESCENCE ............................................................ 1 CHAPTER 2: WHAT IS COUNSELING ............................................................................................................ 16 CHAPTER 3: COUNSELLING SKILLS/TECHNIQUES ....................................................................................... 22 CHAPTER 4: CHALLENGES IN COUNSELLING............................................................................................... 37 CHAPTER 5: COUNSELLING ADOLESCENTS ON PERTINENT ISSUES ............................................................ 47 CHAPTER 6: RELATIONSHIPS ...................................................................................................................... 84 CHAPTER 7: COUNSELING ADOLESCENTS AS PARENTS ........................................................................... 102 CHAPTER 8: CAREER COUNSELING ............................................................................................................ 107 CHAPTER 9: PLANNING FOR THE FUTURE—WHAT YOUNG PEOPLE NEED TO CONSIDER ........................ 110 APPENDICES Scenarios for Counselling Practice ............................................................................................................... A Pre-marital Information Sheet ......................................................................................................................B Adolescent Behavioural and Fertility Indicators for Ghana ..........................................................................C REFERENCES 1. National Adolescent Health and Development Training Manual for Healthcare ProvidersFirst Edition, December, 2005 2. ABC of Counselling Adolescents Towards Behaviour Change, First Edition, 2002 3. Programming for Adolescent Health and Development. Report of a WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health 4. WHO discussion Paper on Adolescence. Issues in Adolescent Health and Development, WHO 2004 ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 2 Acknowledgement This manual was pre-tested by use in teaching ten (10) Regional Adolescent Health Resource Teams and CHAG staff. Over 700 copies have been circulated since the year 2002. Based on comments received from the regions and other members of the national ADHD Resource Team, a revision was done by Mrs. Ophelia Amekudi, Dr. Araba Sefa-Dedeh, Mrs. Faustina Oware-Gyekye, Dr. Edith Tetteh, Dr. Robert K Mensah and Ms. Rejoice Nutakor in June 2005. The final review of the document was done in August, 2008. The revised document was reviewed by the National ADHD Resource Team. Lastly but not the least we will like to thank Ms. Elinam Dellor of the Reproductive and Child Health Department of the Family Health Division of Ghana Health Service for typing the scripts. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 3 Foreword: The Second Edition of the ABC of Counselling Adolescents Towards Behaviour Change The National Adolescent Health and Development Programme is being developed and integrated into the health delivery system in both the public and private health sectors. The main elements of the programme include rights and responsibilities, pre-adolescent and adolescent development, adolescent nutrition, adolescent sexual and reproductive health, substance abuse and other practices that negatively affect adolescent boys and girls, mental health and injuries. A cross-cutting issue such as adolescent health promotion which comprises adolescent health education, counselling, social mobilization and age-appropriate material development for stakeholders has been at the centre of programming. Other strategies used in programming are policy and planning, capacity-building, service delivery and monitoring and evaluation. Counselling has been identified as a key area of emphasis that will go a long way to address the emotional needs of young clients and their significant others. Counselling also provides a forum for fact dissemination and countering of myths and rumours. Professional and lay counsellors are the best people for providing counselling services. Health workers and other stakeholders such as parents/guardians, teachers and social workers best fit in the group of lay counsellors to support the effort of the few professional counsellors we have. Counselling is being integrated into adolescent-friendly health services at different levels of service delivery. However, the health sector has not reached ideal levels of implementation in terms of coverage and quality so far as counselling is concerned. This is partly because we do not have adequate numbers of professional or lay counsellors and the few cannot reach majority of clients who need the services and at all times. This manual, the second edition of the ABC of Counselling Adolescents Towards Behaviour Change was conceived by the Ghana National Adolescent Health and Development Resource team. The technical content of the First Edition was revised in response to experiences shared and suggestions made to enhance the manual. Health workers who used the First Edition made immense contributions to the content of the Second Edition. We wish to thank all the National and Regional Adolescent Health and Development Resource Teams for their immense contributions. We trust that the Second Edition of ABC of Counselling Adolescents Towards Behaviour Change will enhance the knowledge and skills of all users especially health workers. We hope would- be users will continue to give us comments that will contribute immensely to future editions. DR. ELIAS K. SORY DIRECTOR GENERAL (GHANA HEALTH SERVICE) ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 4 _______________________________________________ List of Acronyms and Abbreviations ADH Adolescent Health ADHD Adolescent Health and Development AIDS Acquired Immune Deficiency Syndrome GDHS Ghana Demographic and Health Survey CHAG Christian Health Association of Ghana HIV Human Immune-Deficiency Virus IEC Information, Education, Communication LSD Lysergic UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund WHO World Health Organization ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 5 Adolescent behaviour change is an important component of the biological, psychological and social health of young people. Counselling is a key element for behaviour change in young people. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 6 CHAPTER ONE: UNDERSTANDING ADOLESCENTS AND ADOLESCENCE 1.1 WHO IS AN ADOLESCENT? Although all young people below the age of 18 years are sometimes defined as children, for example in the United Nations Convention on The Rights of the Child (CRC) adolescents are generally defined as those who fall between the ages of 10 and 19 years. Adolescents are tomorrow’s adult population and their health and well-being are crucial. Young people fall within ages 10 and 24 years. Youth fall within ages 15 and 24 years. Young adult fall within ages 20 and 24 years. Adolescents may be further classified as younger (10-14 years) and older adolescents (15-19 years). Globally, adolescents form about 20% of the total population. Adolescent population in Sub-Saharan Africa will grow from 14 to 24.6 per cent by 2050. Nearly half of all people on earth today are under the age of 25—the largest youth generation in history. In Ghana, adolescents form 21.9% of the total population—younger adolescents form 11.9% and older adolescents form 10.0% of the total population. Young people form 30.4% of the total population. Youth form 18.5% of the total population and pre-adolescents (5-9 years) form 14.4% of the population. Adolescents are not a homogenous group in terms of development, maturity, lifestyle, dwelling place, school status, marital status and environmental circumstances. These diversities depend on personal and environmental factors. Being in transition, adolescents may not receive and benefit from the care and protection usually afforded to children and they may not be ready to assume adult responsibilities either. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 7 1.2 WHAT IS ADOLESCENCE? Adolescence literally means growing up. Adolescence is a phase/stage when one is no longer a child and not yet an adult. It is a transitional period between childhood and adulthood. Adolescence is a time of great opportunities and also a time of exposure to certain risks. Adolescence is a time of rapid physical changes, psychological and social changes, excitement, questions and difficult decisions. Adolescence is a time of growth, up to 45% skeletal growth takes place and 15-25% of adult height is achieved. Nutrition influences growth and development during adolescence and nutrient needs are the greatest. This means adolescence provides a window of opportunity for nutrition. It is also a timely period for the adoption and consolidation of sound nutritional habits. Therefore improving an adolescent’s nutritional behaviour is an investment in adult health-correcting past nutritional problems, preparing for a productive and reproductive life and to prevent the onset of nutrition-related chronic diseases in adult life. Adolescence is a period when sexual activities are initiated. Sexually active adolescents place themselves at risks of sexually transmitted infections, unwanted pregnancy, unsafe abortions and their rippling effects. Adolescence is a period when hereditary mental illnesses may manifest for the first time. It is also a period when most people engage in use of substances such as cigarettes, alcohol and other drugs for the first time. Adolescence is a period when young people engage in violent behaviours or reactions to situations. Adolescence is staged into early (10-13 years), mid (14-16 years), and late adolescence (17-19 years). ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 8 Physical Development in Adolescence In pre-adolescence biological changes occur. In females, the ovaries mature, fallopian tubes expand, the uterus enlarge and the vagina matures. In males, the testes mature, the penis enlarges and the scrotum descends into scrotal sacs, seminal vesicles enlarge and prostrate glands mature and commence full functioning. During adolescence, development of secondary characteristics occur. This is marked by changes in shape and size of the adolescent boys and girls. In boys, the shoulders broaden, facial hair grows, voice deepens, sperm production and ejaculation occurs, leading to wet dreams. In girls, hips widen, with characteristic roundness, breasts develop, and menstruation begins. In both boys and girls, rapid growth of limbs and all parts of the body occur, there is weight gain pubic and armpit hair grow, sex/genital organs enlarge and acne is common. Wisdom teeth emerge in adolescence. These changes occur between two and four years, on the average. Emotional, Intellectual, and Moral Development in Adolescence Emotional changes in adolescence include the following: sexual feelings become strong, mood changes occur, easily feels embarrassed, adolescents feel closer to friends than to family, they are better able to solve problems, they rebel against parents/guardians, they want to feel independent and they wonder of body changes. There is also the feeling to try new things. All of these feelings are normal. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 9 Social Changes that Occur in Adolescence Adolescents identify with adult behaviours. They express the need for status and recognition, the need for independence, freedom, autonomy, expansion of their spiritual horizon and interest in being involved in community activities. All the above changes that occur are normal. Everyone develops at their own pace, some earlier and some later. Young people often feel uncomfortable, clumsy or embarrassed because of the changes in their bodies. Menstruation and wet dreams are normal. During puberty, a girl becomes physically able to become pregnant and a boy becomes physically able to father a child. They are both not psychologically and emotionally matured to have a child. 1.3 VULNERABILITIES AND RISKS ASSOCIATED WITH ADOLESCENCE It is important for counsellors to understand risk-taking behaviours and young people’s vulnerabilities. This enables counsellors to better serve youth. Some risk-taking behaviours lead to serious life-long consequences, while other risk taking behaviours result in injuries or poor decisions that can be corrected. See below a list of vulnerabilities and risks. Vulnerabilities Physical vulnerabilities in adolescence Rapid physical growth creates need for nutritious and adequate diet. Adolescents may not have enough food. Poor eating habits are common especially with girls Poor childhood health may continue into adolescence thus repeated and untreated infections can compromise physical and psychological development ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 10 Emotional vulnerabilities in adolescence Mental health problems can increase due to changes in physical and social environment Lack of life skills may render them unable to articulate issues They are more vulnerable than adults to sexual, physical and verbal abuse Unequal power dynamics May be unable to make rational decisions Socio-economic vulnerabilities in adolescence Need for money increases Poverty and hardship can increase health risk owing to poor hygiene and inability to afford healthcare and medications Early marriage to escape poverty which may worsen situations Streetism Child labour Youth in criminal activities Orphans Abandoned/neglected Risks Poor physical growth Stunting and thinness Low haemoglobin level especially among girls Deficiencies in iron, calcium, vitamin A, iodine and zinc folate Obesity owing to poor eating habits and hereditary factors ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 11 Poor psychological growth Negative perceptions of healthy issues Inadequate life skills education Sexual risks Too early initiation of sexual activity Unprotected sex (dual protection) Multiple sexual partners Unsafe abortion Risks for Substance abuse Poor judgment Vulnerability to high risk behaviours Unintentional injuries Intentional injuries Addiction to harmful substances Long term disability Sudden death Risks for sexual abuse Injuries to genital area Emotional trauma Sexually transmitted infections including HIV and AIDS Death in pregnancy and abortion ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 12 Risks for physical abuse Injuries to the body Psychological trauma Risks for violent behaviours Physical injuries Curtailment of education Deployment Destruction of available resources Reasons for adolescent risk-taking behaviour a. Major physical, psychological and social changes occurring during adolescence affects adolescent behaviour b. Peer influence gains greater importance over family influence c. Curiosity and sexual maturity leads to experimentation. Peer pressure leads to risky behaviours such as unprotected sex, substance abuse, dangerous recreational activities and reckless driving d. Negative cultural practices 1.4 ADOLESCENTS RIGHTS AND RESPONSIBILITIES Young people like all other people have rights and responsibilities, Since Ghana is part of the global community and has been signatory to all human rights conventions, adolescents/young people within the context of the Convention of the Rights of the Child (CRC) have the following rights and responsibilities: ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 13 Rights Survival rights: the right to life and to have the most basic needs (e.g. adequate standard of living, shelter, nutrition, and medial treatment). Development rights: the rights enabling children to reach their fullest potential (e.g. education, play and leisure, cultural activities, access to information and freedom of thought, conscience and religion). The child or adolescent has the right to refuse marriage or betrothal be s/he a Muslim, Christian or traditionalist. Participation rights: rights that allow children and adolescents to take an active role in their communities (e.g. the freedom to express opinions, to have a say in matters affecting their own lives and to join associations) Protection rights: rights that are essential for safeguarding children and adolescents from all forms of abuse, neglect and exploitation (e.g. special care for refugee children; protection against involvement in armed conflict, child labour, sexual exploitation, torture and drug abuse. Responsibilities Young people have the responsibility of abstaining from initiating early sex, pre-marital sex, early marriage, engaging in confusing and exploitative touches, use or abuse of drugs, engaging in violent behaviours and making wrong choices in their eating habits and general lifestyle. Young people have the responsibility to seek appropriate information about their own health including reproductive health. Young people have the responsibility to stay in school and feel they are in a safe environment. Young people have the responsibility of cooperating with health workers and other stakeholders in transactions related to their own health and development. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 14 1.5 Nutrition in Adolescence Nutrition influences growth and development throughout infancy, childhood and adolescence. During adolescence, nutrient needs are greatest. During adolescence, up to 45% of skeletal growth takes place, and 15 to 25% of adult height is achieved. During the growth spurt, 37% of bone mass may be accumulated. In view of these, adolescence should be considered a high priority life cycle stage for nutrition needs and intervention. Adolescents are exposed to under nutrition, micronutrient malnutrition and obesity and other nutrition-related chronic diseases. The main nutritional issues of adolescents are: - low body stores as a result of malnutrition during foetal life, infancy and childhood. - dietary inadequacies due to socio-economic factors such as access to food and supplies and psychological factors such as eating patterns (inadequate and unhealthy diets) - livelihood factors such as sedentary lifestyle, heavy physical work, alcohol and smoking. - Infectious diseases and other health problems - early pregnancy (adolescent pregnancy and increased nutritional requirement) Malnutrition delays physical growth and maturation in adolescence. Stunting and delayed maturation compound risks of adolescent pregnancy. Poor nutrition may delay the onset of menarche due to decreased available energy. Malnutrition in adolescence reduces work capacity. Iron deficiency is recognized as the main nutritional problem in adolescents especially in girls. Malaria, schistosomiasis, hookworm infections, tuberculosis and HIV may further increase iron requirements in adolescents. The risk of vitamin A deficiency extends into adolescence and early adulthood. This means iron and vitamin A requirements are increased for growth in adolescence. Vitamin A plays an important role in sexual maturation. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 15 Iodine deficiency contributes to mental retardation in adolescence thus contributing to a downward shift in IQs. Foetal, pre and post natal survival is markedly affected by iodine deficiency. Calcium requirements for skeletal growth are greater in adolescence than in childhood and adulthood. Girls especially need adequate calcium intake to reach peak bone mass and to minimise bone loss during menopause. Obesity and associated chronic diseases such as cardiovascular disease, diabetes and cancer are becoming a pandemic and so adolescence is a window period for prevention. Tooth decay is a nutrition related problem in adolescence. It may be a combination of poor oral hygiene and poor eating habits. Early pregnancy is a well documented factor of health and nutritional risk in adolescent girls. Adolescents who are not up to two years post menarche may enter pregnancy with reduced nutritional deficiencies. The pregnancy outcomes of this group of adolescents are more likely to be poor. These outcomes include low birth weight and prematurity, maternal morbidity and mortality and other socio-cultural and economic consequences. Counselling on nutrition in adolescence is very important for integration of health, nutrition and development of adolescents. Nutrition education forms an important component of self care skills for young people. Effective school-based nutrition programmes is a solution to the problem of poor health behaviours of young people. Nutrition promotion is an integral part of health promotion—it involves promoting healthy eating, physical activity and other components of healthy lifestyle which should include promotion of self-esteem and breastfeeding. Prevention management is about preventing micronutrient malnutrition, early pregnancy, under nutrition/malnutrition, obesity and eating disorders. Nutrition clinical case management addresses chronic diseases such as diabetes, HIV/AIDS and others. 1.6 UNDERSTANDING ADOLESCENT SEXUALITY ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 16 Definitions Sexuality is an important part of who a person is and what he/she will become. Sexuality includes our thoughts and feelings about sex, feeling attractive, being in love, religious or cultural views on sexual activity, feelings about a changing body during adolescence, sexual dreams, crushes, hugging, kissing, touching, how we define male or female, how we love and being physically close in other ways. Sexuality and sex are not the same. Sex is whether a person is male or female but sex is also used to talk about sexual intercourse. Sexual intercourse is when an erect penis is introduced into the vagina, anus or mouth. All these sexual activities can put a girl or boy at risk for sexually transmitted infections including HIV. Sexual intercourse puts a girl at risk of pregnancy. Sex is both emotional and physical and so sexual activities carry physical and emotional risks. After a sexual act, a girl or boy can feel disappointed. Therefore it is important that sexual activity must only occur between two people who respect and care for each other and care emotionally, physically, and economically. Sexual activity should be agreed by both people. This means if one person says ‘no’ or ‘stop’, it should stop. No one should be coerced to have sex. Aspects of Sexuality Just as there are many parts that make up who we are, there are many parts that make up sexuality. Our culture, traditional beliefs and gender roles play an important part in defining what we consider normal sexual feelings and behaviours for boys, girls, men and women. Here are some aspects of sexuality: -Body image: how we look and feel about ourselves and how we appear to others. -Gender roles: the way we express being male or female. It is about the expectation people (society) has for us based on our sex. -Relationships: the ways we interact with others and express our feelings for them -Intimacy: close sharing of thoughts or feelings in a relationship-may or may not involve physical closeness -Love: feelings of affection and how we express these feelings for others -Sexual arousal: the different things that excite us sexually -Social roles: how we contribute to and fit into society -Genitals: the parts of our bodies that define sex. They are part of reproduction and sexual pleasure. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 17 Circles of Sexuality Adolescents can experience some feelings that are new and normal but can be frightening. Feelings do not control actions; people choose their actions and behaviours. Sexuality and behaviours are closely linked. Elements of sexuality are sensuality, intimacy, sexual identity, reproduction and sexual health and sexualization. Below are descriptions of the interaction of the elements of sexuality. Sensuality Awareness and feelings about your own body and other people’s bodies. Sensuality enables us to feel good about our bodies, how we love and feel and what the body can do. It enables us to enjoy the pleasure our bodies can give ourselves and others. It reflects our body image-whether we feel attractive and proud of our own body. It satisfies our need for physical closeness-to be touched and held by others in loving and caring ways. These feelings begin in adolescence and it affects how we think, relate to others and behave. Intimacy The ability and the need to be emotionally close to another person and have that closeness returned to us. Intimacy makes personal relationships rich. Intimacy focuses on emotional closeness-liking and loving. People can have intimacy without having sexual intercourse. Sexual intimacy is facilitated by feelings of sensuality. Sexual Identity A person’s understanding of who he or she is sexually involves four (4) things: -gender identity- am I male or female? -gender role- what can a boy or girl do because of gender? -sexual orientation-who am I attracted to sexually-male or female? -sexual preferences-what are my sexual limits e. g. how many partners will I have? Reproduction and Sexual Health Reproduction and sexual health are the capacity to reproduce and attitudes and behaviours that make sexual relationships healthy both physically and emotionally. Sexualization ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 18 Sexualization is a negative aspect of sexuality. It includes using sex or sexualization to influence, manipulate, or control other people. Such behaviours include offering or accepting money for sex, giving grades/promotions to students or employees in exchange for sexual favours (sexually transmitted grades), sexual harassment, sexual abuse or rape or withholding sex from a partner to punish or to get something you want. Being Sexually Healthy There are things that can be done to be sexually healthy. Young people can learn as much as possible about sex and reproduction. They should be able to tell the difference between sexual behaviours that are healthy and those that are harmful. It is important they take time to think about choices related to sexual activity. One of the choices is say ‘no’ to sex. When a young person decides to have sexual intercourse, he/she should remain faithful to one partner as well as protect each other from infections and pregnancy. The consequences of sexual behaviour may be healthy or unhealthy sexuality. Healthy sexuality means: -expressing sexual feelings in ways that are not harmful to themselves or other -not taking risk with one’s own body and how to be sexually safe and healthy -being a virgin is a good protection against pregnancy and sexually transmitted infection including HIV and AIDS. Unhealthy sexuality means: -losing virginity -sexually transmitted infections including HIV and AIDS -unplanned and unwanted pregnancy -complications of abortion -health problems emanating from substance abuse, negative lifestyles such as inadequate nutrition and exercise and risk taking adventures. Setting Limits To engage in sex or not is a big decision to make. We all have control over our bodies for responding to nature’s call in all aspects. It is important for a young person to decide when to have sex, with who to have sex, why have sex, where to have sex, how often to have sex and whether to have sex with or without a condom. Remember that having sex is a decision and it is ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 19 controllable. Sex is not a powerful and uncontrollable force that just happens. Young People Should Remember To Ask Themselves These Questions Before Acting on Any Sexual Feelings Will I or anyone else be put at risk for unwanted pregnancy, HIV or other sexually transmitted infections? Will my actions cause problems such as misunderstanding or miscommunication in our relationship? Will my partner feel uncomfortable? Will anyone’s feelings get hurt? Remember that in Ghana, all religions and almost all traditions approve of sex within marriage only. Sex with close relatives and children is against society expectations and our laws. Sex between same sex individuals is frowned upon/not acceptable. Safe, Safer and Unsafe Sex Safe Sex Safe sex are sexual activities with no risk of HIV transmission. This means all sexual activities between two uninfected people are safe and all sexual activities that do not and could not involve semen, vaginal fluid, or blood going from one person into another are safe. Safer Sex Safer sex are sexual activities with a low risk of STI and HIV transmission. Safer sex is about sexual activities involving a person with HIV infection where there is no semen, vaginal fluid or blood going from one person into another. Safer sex are activities that theoretically safe at this time are not known to have been a route for infection. Unsafe Sex Unsafe sex are high-risk sexual activities such as any practices with a person who might have HIV infection that allows blood, semen or vaginal fluids inside the body through the mucous membrane of the mouth, vagina, penis, or anus or through broken skin. Unsafe sexual activities include: ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 20 -vaginal and anal intercourse without a condom -any type of blood contact including menstrual blood, semen or vaginal fluid entering breaks in the skin -sharing sex toys without cleaning them between partners -any type of sex that damages the delicate tissues in the vagina, head of penis or rectum. For example, rough sex, use of abrasive substances in vagina and dry sex. ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 21 CHAPTER TWO: 2.1 WHAT IS COUSELLING? INTRODUCTION Counselling young people is a key behaviour change and communication strategy. Adolescents experience enormous emotional and physical problems. These problems call for a professional approach to deal with the issues that emanate. Human interaction is an in-built and extremely important component of any programme that addresses young people’s needs. Nurturing children is the responsibility of all stakeholders: parents/guardians, teachers, family members, significant others and the community at large. Counselling young people is the responsibility of trained and lay counsellors. This is because young people cut across all levels of the development system. All international agreements emphasize the rights of young people to obtain counselling towards making informed choices in career, sexual and reproductive health matters among many others. Client centred care, gender equity and equality, reproductive rights and sexual rights are key elements for rights-based programme in adolescent health and development. Counselling young people towards behaviour change has its roots in all the rights-based elements being propagated. The concept of counselling young people towards behaviour change recognizes them as vulnerable groups having reproductive and other health needs. Appropriate referral and maximizing use of available resources are key components for success. Counselling is one of the approaches used in health education to help individuals, families and groups make informed choices. During counselling, a person with a need and a person who provides support and encouragement meet and discuss in such a way that the person with a need gains confidence in his or her ability to find solutions to the problems. Counselling is an ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 22 important aspect of disease prevention and health promotion because it helps people to understand what they can do through their own efforts to avoid illness and to improve their health. Through counselling, individuals are encouraged to think through their problems and thus come to a greater understanding of the causes or contributory factors. With an enhanced understanding, it is hoped that clients will commit themselves to taking action that will solve the problems. This kind of action taken will be a client’s own decision but guided if necessary by the counsellor. Young people need counselling most as their emotions are fragile yet they are involved in a lot of experimentations which sometimes lands them into troubles that affect their health and development. Counselling is a technique to help adolescents’ transition into maturity by strengthening their own self-understanding and powers of decision-making than simply providing advice. The goal of adolescent counselling is to facilitate client growth and improved mental health. This means, counsellors must be willing to walk in their capacity as helpers. The counsellor accepts the young person’s right to make his/her own decisions and believe in and trusts the clients’ ability to do so responsibly. It is important that providers of counselling services for young people respond favourably to the following questions. - Are you trained to offer counselling services to young people? - What do you do to ensure that young people you counsel have adequate privacy, confidentiality and safety? - Do you provide counselling for prevention and promotion of health in the area of nutritional disorders, STIs/HIV, pregnancy, post-abortion care, substance abuse, intentional and unintentional injuries and mental health problems and preABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 23 conception care? - Do you have, adequate time for each counselling session? - Do you consider counselling an important component of the adolescent health and development programme? In programming for young people, up to date information interventions need to be provided to address health and behaviour problems, health services including counselling skills in a safe and supportive environment. The focus of programming sexual and reproductive health services for young people is delaying early initiation of sex, preventing/reducing STIs/HIV, unwanted pregnancy, unsafe abortion, prevention of substance use and mental health problems, injuries, promoting adequate nutrition, self-care, life and livelihood skills are also areas of focus. The main strategies to be used are increasing access to youth-friendly health services, including reproductive health, improving self care, life skills and capacities, improving policy and media environment and resource mobilization. Behavioural Change and Communication approaches such as enter-education and peer education are also useful. 2.2 BASIC COUSELLING There are many definitions of counselling. Most of these highlight the fact that it is an interaction, involves helping and it is concerned with choices and change. The following are some definitions of counselling: o Counselling is a process by which a counsellor assists the counselee in making choices, plans, adjustments or decisions with regard to his/her situation. o It is a relationship in which one person endeavours to help another to understand and solve or deal with his/her problems or concerns. o It is an interaction which occurs: a. Between two individuals called counsellor and client. b. Takes place in a professional setting and ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 24 c. Is initiated and maintained as a means of facilitating changes in the behaviour of the client. o Counselling is a process by which a troubled person (client) is helped to feel and behave in a more personally satisfying manner through interaction with an uninvolved person (the counsellor) who sometimes provides information and interactions which stimulate the client to develop behaviours which enable him/her to deal more effectively with himself/herself and his/her environment. The counselling relationship assists the individual to: i) Understand and accept himself/herself as an individual, thereby making it possible for him to express and develop awareness of his/her own ideas, feelings, values, needs and concerns. ii) It furnishes personal and environmental information to the client as regards his/her plans, choices and concerns. iii) It seeks to develop in the individual a greater ability to cope with and solve problems and an increased competence in dealing with future concerns, in making meaningful decisions and plans for which he/she is responsible. What Counselling Is Not Counselling is not about the following: o Giving of information – even though information can be given when necessary. o Giving advice – since clients are responsible for the consequences of their actions, they must make their own decisions. o Giving of suggestions and recommendations. o It is not admonishing, warning, threatening, forcing or disciplining. o Just interviewing – even though interviewing may be used at times it is not synonymous with counselling. It is used when the counsellor wants personal information about a client. Who is the counsellor? ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 25 The counsellor is the professionally trained person who uses his/her skills to assist the individual (young person) in need. Qualities of a good counsellor include the following: A good counsellor should be – o Knowledgeable o Respectful of the individual as he/she is o Resourceful o Courteous o Trustworthy o Empathetic o Tolerant o Honest o Humane o Genuine/ Sincere o Warm and open o Objective o Responsible o Observant o Tactful o Flexible o Self controlled o Compassionate o Appreciative – appreciation is done to improve situation What a Counsellor is not The counsellor is not and must not be: o A disciplinarian o An investigator o A solver of problems o A unique person ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 26 o Above the rules and regulations o A champion of adolescent causes of problems o A mister/mistress know all, who can do everything. Who is the Client? The client is the individual who needs help in his/her worried state and believes the helper (counsellor) can offer or give such assistance. Conditions that facilitate counselling There are internal and external conditions that impact counselling and make it effective 1) Internal conditions that facilitate counselling a. Respect means acceptance of a client as he/she is and appreciation of him/her as a person or an individual who is unique in all aspects of life. b. Empathy means to feel with another or share another\s feelings; or putting one’s self in another’s shoes (ability to accurately understand what another person is experiencing and communicating that understanding to the person). c. Genuineness means honesty with one’s self and with the client. It is paying attention to another person. It implies the use of verbal and non-verbal communication by the counsellor to show the client that the counsellor hears what he/she is saying and that he/she is interested and cares. 2) External conditions that facilitate counselling a. Physical setting: The room should be comfortable and attractive with appropriate light and ventilation. b. Sitting arrangement: Each personal space within which he is comfortable. Sitting should be close enough for the counsellor to observe the client without difficulty. c. Privacy: Is very important in counselling. If clients are afraid that they will be overheard, they will refuse to open up. To ensure and maintain privacy, there ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 27 should be no opportunity for clients to be seen, or overheard during the counselling process. d. Confidentiality: Is very necessary in counselling. The counsellor assures clients that nothing they say will be disclosed to others without their consent. There are limits to confidentiality e.g. legal and ethical constraints should be discussed with clients during the early parts of the counselling. Confidentiality can be broken if someone’s life is in danger. CHAPTER THREE: COUNSELLING SKILLS/TECHNIQUES 3.1 INTRODUCTION In counselling, there are some basic skills that the counsellor uses. There is a need to practice these skills regularly in order to become very comfortable in using them. These skills can be used with immediate family members or friends in order to practice. As beginners, do not crowd your sessions with all nine skills listed. Use a few at a time and add more as you become more ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 28 comfortable in their use. 3.2 BASIC COUNSELING SKILLS 1. Establishing rapport It is the way in which a counsellor welcomes and makes a client comfortable or put him/her at ease. This encourages the client to trust the counsellor and express him/herself freely. Rapport can be established using non-verbal communication. Non-verbal communication includes (a) Nodding – nod in agreement to what client says (b) Facial expressions – smile and look friendly (c) Eye contact – look client in the face as he/she speaks without staring (d) Posture – lean towards client to show acceptance and attentiveness. Be relaxed. (e) Tone of voice – avoid a monotone or a low voice that is difficult to hear or shrill aggressive tone. (f) Touch – touch client to show acceptance and concern as and when appropriate. Use touch sparingly. Touching the opposite sex can be misinterpreted. Verbal communication includes i. Greeting and self introduction-brief opening conversation on matters other than counselling concerns e.g. name, the weather, commenting positively on client’s appearance puts clients at ease ii. Indicating one’s willingness to help. Use continuation responses e.g. ‘Go on’, ‘I see’, ‘Is that so’, ‘I am listening’, ‘lam with you’, etc ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 29 Exercise on “Establishing Rapport” Health workers and other counsellors should practice receiving two types of clients: (a) A well known person who comes for counselling (b) An unknown person who walks in for counselling In a teaching session stop participant just when he asks about the problem. Let participant identify first the positive things that the counsellor did then the negative ones. Encourage as many as possible to attempt receiving a client. Refer to, ‘Initial Counselling Session’. 2. Paraphrasing/ reflection of conflict As the title suggests, the counsellor restates what the client says in his/her own words. In order to ascertain whether he/she understand what the client meant. Reflect contact only to verify what the client says in order to understand his/her situation better. Use stems such as the following before reflecting. ‘I heard you say…’ ‘If I heard you right…’ ‘You said…’ ‘You just told me that…’ ‘As you were saying…’ “Did you just say...?’ ‘You mentioned…’ End by using: ‘Is that right?’ ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 30 ‘Correct me if I am wrong’ ‘Is that true?’ ‘Clarify that.’ ‘Is that the understanding?’ 3. Reflection of Feelings It is the act of uncovering and making known the feelings that underlie the client’s comments. Reflection of feelings depends on observing and noting expressed feeling. The counsellor reflects in order to help him/her understand and communicate correctly what the client is experiencing. Feelings underlying non-verbal behaviour should also be reflected e.g. Client: ‘My attempt to train my adolescent daughter is yielding no positive result, she stays out late, she talks under her breath, she defies my orders, oh my.’ Counsellor: ‘It seems you are frustrated over your inability to control your daughter.’ Below is a list of words that illustrate feelings that a counsellor needs to use in order to help a client identify what he/she is feeling at a particular moment. VOCABULARY FOR FEELINGS Abandoned Angry Bored Depressed Accepted Annoyed Conflicted Desolate Afraid Anxious Confused Desperate Alarmed Ashamed Crushed Despondent Belittled Defeated Discouraged ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 31 Disinterested Insecure Sad Dissatisfied Insignificant Satisfied Distressed Jealous Serene Ecstatic Joyful Sexy Elated Lonely Shocked Embarrassed Loved Startled Empty Miserable Surprised Envious Misunderstand Tense Excited Needed Terrified Fearful Neglected Threatened Frustrated Nervous Thrilled Furious Pleased Uncertain Guilty Pressured Uncooperative Happy Proud Understood Hateful Put down Uneasy Helpless Puzzled Unhappy Hopeless Regretful Unloved Humiliated Rejected Upset Hurt Rejuvenated Vengeful Inadequate Relaxed Vindictive Incompetent Relived Wanted Inflamed Resentful Worthles ABC of Counselling Adolescents Towards Behaviour Change 2nd Edition 32 Examples of stems to be used to reflecting feelings include the following: ‘I see you are…’ ‘I can see you…’ ‘I sense…’ ‘It must be very…’ ‘You look very…’ ‘It seems you..’ ‘Your reactions show…’ ‘It is possible…’ ‘You are feeling…now’ ‘What you said hurt you deeply’ ‘You feel…and…’ Exercise on Reflection of Feelings Below is an exercise on reflection of feelings. The example has been done for you. Using the vocabulary on feelings, list the feelings on each exercise. Find out from the passage where the feelings were mentioned. Identify also those which were implied, then reflect the feelings for each exercise. Do this with a partner or in groups. Example: A fourteen year old boy tells you that nobody cares about my feelings at all. My parents just tell me what to do. I feel like am nothing. a) What is this person’s feeling? – Ignored, unappreciated, taken advantage of, Unloved, A sense of futility 33 b) Respond by reflecting what you heard – You feel insignificant about the way your parents treat you and you are unhappy about it? Reflection of Feelings, check the accuracy of client’s feelings, as they have been expressed (stated) or implied during the counselling session. ITEM MAIN IDEAS ENDING You feel Content It is true You seem to Your expressions show Your emotions shoe From your lavation you Seem to be in 4. Questioning Questioning is a common and often over-used technique. It indicates the Counsellor’s intention to seek further information. Questions may be either open-ended or close-ended. Closed ended questions elicit ‘yes’ or ‘no’ answers. Questions can also be used in focusing on particular subjects. Open-ended questions provide the client with the freedom to express self as he/she chooses. They require more than a ‘yes’ or ‘no’ response and allow a client to give more information. Words like ‘how’, ‘what’ and sometimes ‘could’ at the beginning of a sentence may reflect openended question e.g. What happened? How do you feel? 34 Could you tell me what you intend to do? 5. Focusing/Probing In counselling, there is sometimes a need to gather more information on a particular subject or thoughts expressed by a client. Questions are used to direct the client’s attention to such specific points e.g. ‘Can you tell me more about what happened yesterday? (a) ‘You mentioned your father just remarried, can we talk about him now? (b) ‘What happened yesterday?’ 6. Confronting Sometimes, there is the need to gently point out to clients that there are inconsistencies in what they are saying or in what they say and what they do e.g. ‘You say you are not angry but you consistently squeeze your face and look tense and troubled whenever you talk about your friend Jane and what happened last week?’ ‘You say you have no problems negotiating condom use with your boyfriend but you have had two abortions within a year. Help me understand.’ 7. Summarizing The Counsellor condenses, restates and highlights the content and feelings of what a client communicates. This can be done during a counselling session, at end of a session or after a series of sessions. Summarisation is frequently used in any of the following situations (this is not an inclusive list). a. When the counsellor wishes to structure the beginning of a session by recalling the major points of a previous interview. 35 b. When the client’s presentation of a topic has been either confusing, lengthy or just plain rambling. c. When a client has seriously expressed everything of importance to her on a particular topic. d. When plans or the next step to be taken require mutual assessment and agreement on what has been learnt so far. e. When, at the end of a session, the counsellor wishes to emphasize what has been learnt within the session. Perhaps in order to give an assignment to the client before the next session. 8. Listening Listening is the art of paying attention or trying to hear. Listening requires, first of all, that we must not be pre-occupied, for if we are, we cannot fully attend. Secondly, listening involves hearing the way things are being said, the tone used, the expressions and gestures employed. In addition, listening includes the effort to hear what is not being said, what is only hinted at, what is perhaps being held back, what lies beneath or beyond the surface. We hear with our ears, but we listen with our eyes, mind, heart, and skin as well. Listening has to be learned and practiced. Suggesting goals in listening. i. How the client feels about himself and thinks how he perceives himself. ii. What he thinks and feels about others in the world, especially significant others. What he thinks and feels about people in general. iii. How he perceives others relating to him; iv. How he perceives the issue to be discussed, what he thinks and how he feels about what is involved. v. What his aspirations, ambitions and goals are. vi. What defence mechanisms he employs. vii. What coping mechanisms he employs. viii. What values he holds, what his philosophy of life is. 36 How to listen Listening attentively involves concentration. To listen properly a counsellor should: i. Be relaxed, clear your mind and concentrate on what client says, how he/she says it and why. Listening involves hearing what is said and watching how it is said. ii. Give you whole attention to the client and use your body language to let him/her know this – smile, nod, look at the person, lean towards him/her, use continuation responses to help him/her continue talking. iii. Let the client know you understand what he/she is saying by periodically checking to see if you have understood what he/she is trying to tell you. (Reflecting content or paraphrase). iv. Stay to the topic the client introduces. This helps to focus attention and encourage the client to develop and pressure the subject introduced. Do not change the subject or interrupt unless you are clarifying a point. v. Notice the client’s feelings and talk to him/her about what you notice e.g. ‘I realized what happened made you very angry.’ (Reflect feelings). vi. Ask questions to help you understand better. Use open ended questions. vii. Summarize the client’s concerns. Exercises on listening In groups of two, let one read 4 verses of script of choice. Read slowly. The second person listens attentively. After the reader stops he tries to recall what had been read. Active listening - Indicate to the client that you care - Reassure client that discussion is worthwhile - Provides support - Assures the client that you heard his/her message - Communicates respect - Helps the client explore options and solve problems without depending on others. 37 Possible barriers to listening - Going on mental errands - Making assumptions - Being concerned about what to say in response - Getting distracted by a subject the client brings up, that strikes an emotional cord in the counselling. - Lack of privacy. 9. Giving Feedback Feedback is another method of holding up a “mirror” in which clients can see their behaviour as described by the counsellor. Feedback is communication that indicates the effects of a persons’ behaviour on another (or on a situation). It is a comment on the actual or possible consequences of behaviour. It is not a criticism. Criticisms involve evaluation, whereas feedback describes it. A description of the behaviour “When you were talking about your life’s incident several years ago, your voice was very soft and you turned to look at the floor a lot”. The effect of the behaviour “I had to strain to hear what you were saying” Possible alternative: “Can you look more at me as you share your life’s incident?” 38 Effective feedback is: - descriptive rather than evaluative , and focuses on “what” not “why” - Specific rather than general - A description of the behaviour the receiver is capable of modifying - Given as close to the event as possible. Immediate feedback is the most useful - Verified to make sure the receiver has heard and understood the message accurately. 3.3 STAGES IN COUNSELLING Counselling is an on – going process. This means it has a beginning, goes through varius stages and proceeds to an end. The process is in three stages. The beginning is the exploration stage where the counsellor establishes rapport and puts the client at ease (in a relaxed state). This enables both of them to explore their thoughts, feelings, and behaviour during the middle stage and leads to an end stage where actions are taken to effect change. Any encounter between a counsellor and a client no matter how long it lasts is called a session. There could be one session or more, but there could be all the stages in a session. The Beginning Stage – Establishing a relationship with the client and obtaining a clear definition of the client’s concern. It is about doing the following: - Greet client and welcome him/her - Use body language to express warmth and acceptance - Explain who you are - Find out what client’s expectations are - Discuss the duration of each interview, the times and days you will be available and limits to confidentiality. 39 The Middle Stage – The emphasis is on understanding. The counsellor uses his/her skills to gain a better understanding of the client and helps him gain a better understanding of himself and his situation to enable him to make plans of action. This stage involves - Learning more about the client: use open-ended questions and active listening skills to learn more about client especially in specified areas like personal, family, marital and sexual history. - Focusing: mutually identify client’s most pressing need and work on priority issues that need to be resolved. Use internal and external resources to help in decision making and resolving issues. The middle stage is also a stage of self-exploration and self-understanding or the client. Use open-ended questions and listening skills to learn more about your client in specific areas e.g. personal, family, marital and sexual, history, support system available to him/her, adjustment and coping skills. Use reflection of feelings and content/facts to help explore client’s feelings and experiences as they relate to his/her problem. Help client to identify the resources he/ she has which will assist him/her to solve problems. Identify what client has used to solve problems successfully in the past, e.g. external support systems used in decision making and in resolving issues. The Ending stage - The end stage is the stage of action. This stage consists of making action plans and terminating counselling session or the process. (a) Action plans – Help client develop programmes that will help him/her solve her/his problem once he/she has gained insight into his/her problems. Assist client to generate alternative action plans and assess consequences of plans. Help client decide on the best alternatives and implement his/her plans. (b) With support and encouragement from counsellor, decisions are made and implemented; appropriate actions are taken and problems are resolved or coped with. The counsellor then gradually reduces his/her role as the client becomes able to think through and deal with his/her own problems/concerns. 40 (c) Ending – Counsellor gradually weans client from the relationship. The client is able to plan, implement actions, and makes sure concerns have been or are being resolved. Client can now function adequately and is capable of coping with any future situations. Assure client of willingness to help when it is needed. Both the client and the counsellor should be aware that the session is closing and this should be brief. Do not introduce any new ideas or issues. Action Plans A. B. i. Help client decide what he/she is going to do ii. Help generate alternate action plans iii. Help assess consequences of plans and decide on best alternative iv. Help client implement plan. Review Counsellor supports and encourages the client to maintain helpful behaviour changes. Note: These counselling stages are to help a working model or counsellors. Be flexible. Counsellors need to ascertain what help clients need most and what their greatest concerns are and counsel to meet the needs expressed. 41 The Stages Beginning Step I: Awareness of need for help Step II: Development of relationship and overcoming resistance. Middle or Working through Step III: Expression of feelings and clarification of problems Step IV: Exploration of deeper problems Step V: Working through the process Step VI: Development of awareness Ending Step VII: Development of action plans for implementation Step VIII: Termination, adjusting back into society and follow-up The process means moving systematically from one stage to the other as outlined above. Limits- At the beginning of an interview, there must be some mutually approved ideas about setting limits. Time limits are the times of appointments and what happens if the appointment times are to be missed and how tardiness is to be handled. Time requirements that are too loose disturb the effectiveness of the interview relationship. However time limits are handled and judged differently in various cultures. The counsellor must adjust the time specifications in accordance with his/her own needs as well as the client’s needs within the client’s cultural context. Action limits- breaking windows, chairs and equipment. A client can express dislike or the counsellor but cannot attack him/.her physically. 42 Structuring is the counsellor’s definition of the nature, limits and goals of the counselling process. It can be compared to a road map showing the client where he/she is, who the counsellor is and why he/she is there. It is comparable to driving on the highway on a foggy night. The client drives but the counsellor provides the sign and the illuminated white line in the middle of the road, Each person is travelling through lie as if he/she were in a boat, going down a river. The banks of the river provide structure or the river not to flow in all directions. o Limits should be minimal so as not to discourage the counselee. o Limits should be applied non-punitively in order to maximise positive outcomes o Limits should be well defined in regard to action, time and number of appointments in order to boost understanding between the counsellor and counselee(s) o Limits should be structured at the proper time to avoid any misunderstanding. o Too early or too rigid limits will destroy the relationship. Practicing Counselling (Practicum) The practicum period provides counsellors an opportunity to begin counselling under supervision and direction. There are many ways to conduct practicum. The following exercise presents a few variations of methods which have been found to be useful. Read over the various methods of conducting practicum and decide which method or combination of methods you prefer. 1. FISHBOWL: A practicum done in a fishbowl is one in which two members of the group, one playing the role of the counsellor, the other playing the role of counselee are seated in the middle of the room. The rest of the group is seated in a circle surrounding the group. The dyads in the centre begin the counselling sessions and the members observe and critique the session. After about twenty minutes have passed, t he members consisting of the 43 counsellor and counselee end the session. The group leader and members give feedback to the counsellor concerning how they observed the session. 2. DYADS: The group divides into groups of two. Each group of two finds a spot away from the other members to conduct a counselling session. One member of the dyad plays the part of the counselee for forty minutes while the other plays the part of the counsellor. After the forty minutes are up the two members discuss and critique the session for fifteen minutes. The roles are then reversed and the session ends. During this time, the group leader circulates and observes all the sessions, moving from dyad to another until he/she has observed each session. At the end of the exercise the entire group meets to discuss what they have learned from the exercise. 3. TRIADS: The group divides itself into three groups consisting of three members apiece. One member is the counsellor; the second member is the counselee; and the third member is the observer. Each member plays one of the various roles for twenty minutes apiece, rotating roles until all have had the opportunity to counsel, observe and be counselled. The observer member makes notes on the sessions and gives feedback to the counselee and the counsellor after each counselling session. The group leader circulates and observes every group. At the end of the exercise the entire group comes together and discuss the exercise. 44 45 CHAPTER FOUR: CHALLENGES IN COUNSELLING Preamble Counselling sessions are fraught with several challenges. Challenging moments in counselling are those special moments when reactions or responses from clients suggest discomfort or when the counsellor finds it extremely difficult to continue with the counselling session. 4.1 Difficult Moments In Counselling A number of different but rather difficult moments are experienced by counsellors who work with adolescents. Below are some typical examples of such moments and suggested strategies to deal with them. Silence This is when a client is unwilling or unable to speak for sometime. It is a common thing in adolescents who are very anxious or angry, usually because they have been forced against their will. Silence can occur at the beginning or middle of a session. When this happens, the counsellor should respect the feelings of the client. The counsellor should show understanding of the situation. It is best to wait as the young person makes an effort to express his/her feelings or thoughts. Do not become uncomfortable with the silence and break it just so there is talk. If time constraints make it impossible to reflect; wait and indicate so and fix another appointment. The Client Cries A client who starts to cry or sob may make the counsellor uncomfortable but the counsellor should allow the client to cry .At times clients may use crying to elicit sympathy, favour or stop counsellor from asking further questions. Identify feelings involved and reflect on them appropriate. After a while the client should be encouraged to talk. 46 Client tries to manipulate counsellor Some adolescents are good at getting what they want from other people by subtly controlling them. For example, an adolescent may ask for help with a problem but what they really want is the counsellor’s attention or time or to be on their side in some family conflict. When a counsellor suspects a client is doing this he/she must raise this with the client. He/she should point out that such tactics do not help in learning more responsible ways of relating to others. In order not to be manipulated in this way a counsellor must periodically be asking himself/herself the following questions: What does this client really want? Am I going beyond my responsibilities as a counsellor? Am I being manipulated? The counsellor cannot establish good rapport It is difficult sometimes to establish a positive/good relationship. Do not end the relationship if the adolescent is willing to continue it. If he/she is not willing, consider a referral to another counsellor. Review sessions and find out why or where the fault lies. Try to continue counselling/helping client so that he/she feels better and learns more about him/her. If the adolescent is not willing to continue with the relationship, explore with him/her a referral to another counsellor. The Client threatens Suicide (killing himself/herself) Do not take a threat of suicide lightly, it could happen. Though some young people, who threaten to take their own lives are just crying for attention. People who take their lives often feel hopeless and helpless. They believe they have no one who cares for them. The counsellor 47 should show concern and give reassurance. The counsellor signs a contract that he cares. At times some adolescents threaten in order to get their own way or get what they want. It is better for the counsellor to comment on positive feelings noted in him/her; this is encouraging enough to show interest. The lay counsellor should refer the adolescent to the appropriate support system in the community. It may be necessary to break confidentiality. Counsellor is embarrassed by the subject matter Adolescent may ask or tell the counsellor something that may make him/her very uncomfortable and difficult to answer. It is best for the counsellor to be honest with the adolescent if he/she showed any sign of feeling uncomfortable. He/she should acknowledge having had such feeling by talking about it and going back to the topic they were dealing with. Client refuses help Sometimes an adolescent may refuse help. If this happens during the counselling session, the counsellor should find out the reasons in a caring way. If the client was sent to the counsellor without the parents not telling him/her what they wanted to do, reassure him if he/she is unwilling to talk and angry about the whole issue. Offer him/her the chance to come when he/she feels he/she needs your services. Do not force him/her (client). Self-disclosure This technique involves a counsellor sharing his/her own pertinent life experiences with a client. A counsellor can use this technique when he/she knows the client well. Since the technique involves revealing the counsellor’s own feeling, life experiences and emotional concerns. The counsellor should use his/her discretions. There is a risk of shifting the focus from the adolescent to the counsellor. The counsellor should ensure that this does not happen. 48 Client flirts with Counsellor The adolescent may attempt to flirt with the counsellor using smiles, eye contact or exposing part of his/her body. Sometimes the adolescent’s body language may be accompanied by praise or sexy words. It is important for the counsellor to show maturity by ignoring the advances being made by the client. If the client continues then the counsellor may comment on the behaviour of the client. For example, “Julie, several times now you’ve asked me if I’m married and if I ever go out with my clients. I am becoming uncomfortable with this. I might be wrong but I sense that you are interested in me. My discomfort about this is that if this kind of relationship/conversation continues, I will be unable to address your concerns properly.” If it persists the counsellor should refer the client to another counsellor. The counsellor and client know each other socially In small communities, the adolescent client will know who the counsellor is and may know him/her quite well. If the relationship is a casual one, it may be possible to serve as a counsellor, but it must be made clear earlier on that confidentiality will be totally respected and that the way you will relate to your client is quite different from the way you will relate to a friend or acquaintance. If, however, you are well known to each other, it is not possible to serve as a counsellor. It will be necessary to explain that to client and rearrange for someone else to help. The counsellor must indicate that in his/her experience, it is not helpful to work with someone he/she knows socially because it is a different kind of relationship. While a friend might want to be comforting or one might get angry or be embarrassed by something he does not like, the role of a counsellor is a different one. It is not possible to change roles when meeting outside the counselling session, and this will inevitably give rise to confusion and hurt feelings. 49 4.2 CO-COUNSELING Co-counselling refers to joint counselling by two or more counsellors at the same time. It can be particularly useful in family or couple counselling especially when two counsellors are of different sexes. With one client especially an adolescent, it is not recommended as it can be rather overwhelming and inhibit the adolescent from talking. Below are some suggestions for co-counselling if it is to be used. Issues in co-counselling – what co-counsellors should do Before Session: - Clarify objectives - Discuss client needs - The role each counsellor will play - Identify any differences regardingo Objectives o Methods/ styles o Expectation from clients - Agree on over all approach - Achieve amicable relationship During Session: - Support co-counsellor if helpful to client - Help co-counsellor during difficult moments - Reflect client’s view if co-counsellor seems to be misreading it - If disagreements of details arise, deal with them openly but amicably After Session: - Review session immediately afterwards - Discuss and resolve any differences - Seek help from third party if necessary - Plan next step 50 4.3 GROUP COUNSELING Group counselling is a dynamic interpersonal process focusing on conscious thought and behaviour. It involves therapy functions of permissiveness, mutual trust, caring, understanding, acceptance and support. The functions are created in small groups of 6-8 through the sharing of personal concerns with peer group counsellor(s). Group counselling is viewed as a routine adjustment or development experiences provided in a group setting. It is also the group process, which is continuous, on-going movement of a group toward achievement of goals. It represents the flow and activities toward achievement of its goal. It is also a means of identifying or describing the stages through which the group passes. Group counselees are basically normal individuals with various concerns which are not debilitating to the extent of requiring extensive personality change. Group counselees may utilize group interaction to increase understanding and acceptance of values and goals, to learn and/or unlearn certain attitudes and behaviours. Potential clients for group counselling include: underachievers , potential drop-outs, retarded children, social isolates, thieves, waywardness, step mother, step father, harassment, misconduct, truancy, unrest at home, sibling rivalry, unhealthy relationship, boy/girl relationship, delinquency, adolescent couples, adolescent and family, adolescent and drugs. Types of groups used in group counselling Closed groups – membership is closed to other people other than those who joined at the beginning. Family counselling groups – families come to the sessions, sometimes for one to three days through which all the family members are helped to make better adjustments Study groups – members come together to learn e.g. Bible study 51 Open and continuous groups – in such groups replacements are made when a member leaves. Marathon groups – an intensive living in kind of therapeutic experience with a group of about 12 and therapist. It may operate for about 24 hours. Church/ Religious groups – Bible study, choir, intercessors. During interaction there is increased understanding and acceptance of values and goals, attitudes and behaviours are learnt and unlearned. There is permissiveness, mutual trust, caring, understanding, acceptance and support for each other. Advantages of Group Counselling - It reduced dependency upon a single authority figure. - It increases individual safety in a highly competitive group. - It encourages an open sharing of ideas. - It stimulates greater perception among the group. - It provides for a maximum output in a short period of time. - It provides participants with immediate feedback on their problems. - It helps to ensure a non-evaluative climate at least in the sharing stage. - It tends to be enjoyable and self stimulating. - It develops some degree of accountability for ideas among the group since they have been generated internally and not imposed from outside. Group members gain the most out of a group when they: - Pay close attention to their feelings - Get involved by sharing about themselves - Come to the group with personal goals to be accomplished - Narrow their thoughts/ feelings to specific situations they are dealing with - Ask group members for feedback and are receptive to this when given - Give direct feedback by talking to other group members - Begin recognizing certain defence mechanisms in use - Express positive observations about themselves and others. - Keep confidentiality and privacy 52 Group members do not receive much help when they: - Do not share personal information - Dwell on telling stories about wild experiences - They do not get involved - Attempt to control the group by interpreting, interrupting, questioning, labelling, gossiping, changing or arguing with other members in the group Except immediate resolution - Group Counselling Process In group counselling there must be goals set, just as the individual counselling works towards certain goals. The counsellor determines what he/she intends to do or the sort of help he/she intends to offer. This is communicated to individuals. It could also be that a few clients have come with similar needs and can be easily grouped for counselling. There is therefore the need for an initial individual counselling before clients are grouped together. Counsellor would have found out the background, nature of problem, severity of stress, goals of every individual before grouping them. Clients are told they will work in a group situation soon. Counsellor gives a tentative appointment to all members and on the said day, the group meets for the first time together. Procedure 1. Counsellor welcomes members as they come in; he/she makes them sit comfortably and makes ‘small talk’ with them as they wait for other member. Talk generally about any comfortable topic that the clients brings (other than the problem). 2. When all the clients arrive, counsellor greets and introduces himself/herself again. 3. He/she states the purpose of the group/ group goals. 4. Group members introduce themselves in any of the following ways a. Couples – counsellor introduces males and asks the males to introduce the females 53 b. Individuals – write name and give background information including likes, dislikes, values etc. on a piece of paper. Clients pin these on their chest and move around to read others’ write-ups. Information gathered is shared. 5. Rules are set by facilitator - Time of meeting - Need to be punctual and regular - No private visits to counsellor after group has started - No name calling, blaming, teasing, threatening or aggression - Speak directly to the person you are addressing – look at him - Speak for yourself - Allow 2-4 people to speak before you can speak again - Take responsibility for your choices - No food or alcohol while counselling in session - Don’t leave the group without permission - If you are spoken to, try to listen intently and try to hear what is said - Don’t ask ‘why’ 6. Confidentiality is established Every member, after listening to why information discussed at each session should not be with others or in case of couples outside, is made to promise or swear an oath of secrecy. 7. Roles of every member are discussed. The counsellor explains the need for self disclosure and willingness to share and grow. Members are encouraged to speak and share their concerns and feelings as naturally as possible. 54 Counselling Adolescents With Family A lot of adolescents who attend counselling sessions do so on the advice of their families, and it is not common for them to be seen, at least initially, with one or more of the family members. While the same basic principles apply to family counselling as to individual counselling, some special considerations are necessary because of the complexity of the situation. These include attention to references to responsibility and authority, vested in different members of the family and the need not only to the individual, but also the family as an effective unit. Counselling Adolescent Couples Adolescents who come for help will not usually be part of a stable relationship so that counselling of couples may be uncommon in many services. However, when it is appropriate, couple counselling can be a very valuable way of helping the maturing process of adolescents. It is often helpful for a couple to be counselled by two counsellors, male and female, working together, but it is by no means essential. Issues In Counselling Couples - Thank both for coming - Learn who initiated the decision - Learn what made them come to the session - Explain counsellor’s role is to help - Separating them is not desirable but if necessary it should be done only at the outset and not repeated - If they express differences, reflect them - Observe how they react to each other - Help each listen to the other during the session - Help them to express their emotions - Allow argument or crying for a time - Reflect how they react to each other - Summarize neutrally at the end - Praise them for having the courage to come - Emphasize positive aspects and achievements - Discuss follow-up plan 55 CHAPTER FIVE: COUNSELING ADOLESCENTS ON PERTINENT HEALTH ISSUES Preamble: As adolescents become adults, they consider sexual relations, marriage and parenthood as signs of maturity. They seek information and clues about sexual and other aspects of life from a variety of sources including parents, peers, religious leaders, health providers, teachers, magazines, books and mass media. Adolescents make decisions within the context of the culture in which they live. Decisions and actions may be affected by violence, use of drugs and alcohol, school attendance, work, economic opportunities, self-image and autonomy in decision-making. As a service provider, you can be a valuable source of accurate information for young women and men. You can offer information and reassurance, answer questions and provide a variety of health services. The most pertinent health issues for adolescents today are sexual and reproductive health, substance abuse and alcoholism. 5.1 SEXUAL HEALTH The World Health Organization (WHO) defines sexual health as the integration of the physical, emotional, intellectual and social aspects of sexual being in ways that are enriching and enhance personality, communication and love. Fundamental to this concept are the right to sexual information and the right to pleasure. Violence, coercion, discrimination, fear, shame, guilt, false beliefs and lack of knowledge about sexual issues are barriers to sexual health that many adolescents face throughout the world (Network Family Health International, Vol.21 No.4, 2002). Service providers can help by discussing in a respectful manner with adolescents aspects of their lives that impede optimal sexual health. Important aspects of sexual health that need to be discussed are pregnancy and abortion, contraception, sexually transmitted infections (STIs), personal hygiene and preconception care. 56 Factors that affect Adolescent Sexual and Reproductive Health a) Economic Incentives/Poverty/Unemployment Poverty is wide spread in Ghana. Currently, it is estimated that one out of three Ghanaians lives below the poverty line. Thus, most families are exposed to low standards of living characterized by poor quality of life and limited access to certain basic social facilities. The high levels of poverty coupled with high cost of catering for children have made it difficult for many parents to provide their children with the needed care and attention. In some instances, unemployment compels the adolescent female to fall into early sexual relations with older men (sugar daddies). In extreme cases, they may be drawn into prostitution. b) Parental Care and Support In a pro-natal society as Ghana, it is not unusual to find some parents boasting of their fertility achievements. Many of these parents, however, do little to cater adequately for the very children they boast about. Thus, child care is not seen as necessary complement to childbearing and this results in significant levels o parental neglect and single parent households. This situation is further worsened by the gradual corrosion of the traditional family and community controls. c) Separation, Divorce and Single Parenthood The rate of separation and divorce in recent times has increased. According to the 1998 GDHS, 4.6 percent of females aged 15-49 years were divorced. The incidence of single parenthood and femaleheaded households has a negative impact on adolescent fertility and reproductive health. 57 d) Early Menarche and Sexual Activity Physical growth and development depends on one’s genetic endowment and several environmental factors. Certain environmental factors such as nutrition, medical care and standard of living can accelerate or impede the rate of growth. These factors have contributed to the early onset of menarche (first menstruation) in recent times. Some girls are having their menarche at the age of ten. Menarche and sexual activity both render the individual capable of conception and predispose the individual to becoming sexually receptive. e) Changing Societal Values The traditional systems of preparing for adult life (puberty rites) are being threatened, resulting in the loss of parental and community guidance in the area of sexuality. At the same time, urbanization, modernization and migration with its accompanying problems such as housing shortages, increased female education, and exposure to mass media and foreign cultures. These will increase the opportunity for early sexual expression. Consequences of Adolescent Sexual Activity i) Sexually Transmitted Infections and HIV/AIDS Adolescents are usually involved in unprotected or unsafe sex and thus they are vulnerable to sexually transmitted infections including HIV/AIDS. ii) Health Risks of Early Pregnancy Early pregnancy often carries a great deal of health risks. This is due to the fact that they are not fully matured and are likely to get complications such as anaemia, pregnancy-induced hypertension, obstructed labour leading to operative deliveries and potential visico-vaginal fistulas, etc. 58 iii) Unsafe Abortion In Ghana as in most sub-Saharan African countries, abortion is illegal, unless the pregnancy was a result of rape, incest or the pregnancy threatens the life of the expectant woman or if the woman is a female idiot. Therefore, most young people seek for the services of untrained health personnel. These adolescents are liable to develop lots of complications and even death. iv) Social and Educational Consequences The remarkable consequence of adolescent fertility is societal rejection, dropping out of school and missing life opportunities. The other consequences are ‘streetism’, drug pushing and armed robbery. (v) Pregnancy and Abortion Pregnancy Early initiation into sexual activity and the tradition of early marriage often result in early childbearing among girls in many African countries. This puts the health of young girls at high risk and exposes them to a number of challenges. It is important that the health care provider in counselling the adolescent girl discusses each of these issues: Adolescent pregnancy is likely to be concealed for as long as possible, jeopardizing both the mother’s health and the unborn infant. Since the subject of adolescent sexuality remains a taboo in most societies, there is widespread ignorance among people of the risks associated with unprotected sexual activity. Sources of accurate information and contraceptive advice are rarely available for them. Anaemia during pregnancy, retarded foetal growth, premature birth and complications during labour are all significantly higher for the adolescent mother, as are the risks of her own death during pregnancy or childbirth. Failure to meet the increased nutritional requirements imposed by pregnancy may result in stunted growth and damage the adolescent girl’s future health. Some complications of adolescent pregnancy, including abortion, vesico-vaginal fistula and infertility may result in rejection by husband, family and society. 59 Motherhood in adolescence usually mean an end to education, training, and economic opportunities for the development of the female adolescent. (vi) Abortion Termination of unwanted pregnancy through abortion is a great risk to the health and life of an adolescent girl. All abortions carry a risk. They may result in a range of complications such as bleeding, shock, infection, damage to reproductive organs, tetanus, sterility and even death. However, unsafe abortions are riskier for obvious reasons. Adolescents need to be counselled on where to find information on sexual issues – from parents, teachers or any other knowledgeable person an adolescent respects and trusts. The adolescent girl can avoid getting pregnant prematurely by delaying age at marriage, abstaining from sexual intercourse before being in a stable and responsible relationship, use of condoms and other contraceptive methods and avoid reading and viewing pornographic materials. Addressing consequences of Adolescent sexual activity (i) Contraception Not all adolescents are sexually active, but the numbers increase with each year of age. Although abstinence is the only completely successful protection, all adolescents need to have information concerning safe sex practices to be prepared for the occasion when they wish to be sexually intimate with someone. It is important that appropriate contraceptive services for adolescents are viewed from the perspective of dual protection. The condom (male/female) is the only contraception that offers dual protection against both pregnancy and HIV/AIDS. The service provider must be knowledgeable about these methods and help the adolescent make an informed choice of an appropriate method including dual protection. 60 Contraceptive methods are classified under the following headings: a) Traditional Methods – e.g. Lactational Amenorrhoea method, withdrawal, abstinence, use of herbal preparations b) Natural Methods – i.e. Fertility Awareness Methods such as calendar, symptom-thermal, ovulation methods, etc. c) Modern Methods – e.g. oral pills, injectables, condoms and implants (ii) Abstinence Abstinence is refraining from vaginal, anal, or oral sex. It is an effective way of preventing pregnancy and STIs including HIV/AIDS among adolescents. There are two types of abstinence – primary and secondary. Primary abstainers have not yet had sexual experience. Secondary abstainers are sexually experienced persons who have chose to avoid further sexual activity. Abstinence is the most effective way of preventing unwanted pregnancy and STIs/HIV/AIDS. The adolescent avoids sexual intercourse until he or she enters responsible and emotionally fulfilling relationship such as in marriage. Advantages Everybody can choose to abstain No unwanted pregnancy with its attendant complications It enhances self image of adolescents Cervical cancer is rare in adolescents who abstain from sex Uninterrupted schooling and vocational training, thus ensuring development of full potential of the adolescent. Disadvantages Possible loss of a boyfriend or a girlfriend leading to unhappiness especially if self esteem is low. Long abstinence may cause tension. 61 User’s Instruction The adolescent should: Decide what he or she wants to do about sex Discuss the decision to abstain with partner Avoid compromising sexual situations and stay sober Decide in advance what sexual activities he or she would like and discuss with partner Learn about emergency birth control options, in case you have sex when you did not expect (iii) The Male Condom The male condom is a very thin, flexible sheath that is used to cover the man’s erect penis during sex. It keeps sperm out of the woman’s vagina. It forms a physical barrier between the penis and vagina. The tip of the condom serves as receptacle for semen when the male ejaculates, thus preventing sperm or micro-organisms from entering the female’s reproductive tract. Advantages It is effective and reliable in preventing pregnancy, STIs/HIV/AIDS when used correctly and consistently. It is widely available in family planning clinics, pharmacies, community shops/agents, vending machines, petrol stations, restaurants, peer educators, etc. Easily accessible without prescription or medical assessment Can be used as a back up to other contraceptive methods Enables the male to take responsibility for preventing pregnancy May protect females against cervical cancer Disadvantages Some users may be allergic to latex condoms Wearing it or changing it interrupts the process of sex 62 Some males may report decreased sensation Because of potential for human error, can be less effective that the other contraceptives. User’s Instructions Obtain your condom from a place where they are covered and stored in a place away from the sun Check the package and make sure it is not open or torn Check the manufacture date and add five years to it or check the expiry date. Clients should be instructed to use emergency contraceptive pills as a backup method when condom breaks or slips (iv) Female Condom It is a strong, thin, soft, loose fitting polyurethane sheath. It has two flexible polyurethane rings. One ring lies inside at the closed end of the sheath and serves as the insertion mechanism and internal anchor over the cervix. The outer ring forms the external open edge of the device and remains outside the vagina after insertion and during sex. It is pre-lubricated with a silicon-based lubricant. It does not contain spermicide and must not be used with the male condom. The female condom lines the vagina, creating a barrier against organisms that cause STIs such as gonorrhoea and syphilis, and HIV/AIDS. It also protects against pregnancy. Advantages and disadvantages of the female condom are similar to that of the male condom. (v) Oral Contraceptives The oral contraceptive pill is actually a series of pills containing one or two synthetic compounds similar to the hormones that stimulate the menstrual cycle when taken as directed. They are taken orally every day and cause systemic changes that prevent pregnancy. There are two types – progestin-only pills (POPs, mini pills) and combined oral contraceptives (COCs). The last week of pills are iron containing. 63 How the pills work o Suppression of ovulation in many cycles o Thickening and decreasing the amount of cervical mucus, making it difficult for sperm to pass through the cervix o Creation of a thin endometrium, making implantation less likely Advantages Easy to use and does not interrupt sex Menstrual periods may be less painful May help prevent benign breast disease, pelvic inflammatory disease, endometrial and ovarian cancer Prevents iron deficiency anaemia Disadvantages Does not protect against STIs/HIV/AIDS Interaction with certain drugs such as barbiturates, anticonvulsants, antifungal drugs decrease the effectiveness of the oral pill It may also decrease the effectiveness of several medications (oral hypoglycaemic and oral anticoagulants) Menstrual cycle disturbances such as spotting, amenorrhoea and irregular bleeding Taking oral pills daily could have compliant problems Privacy could be compromised User’s Instruction Must be taken daily to be effective, should be taken within three hours if the same time every day. 64 If you miss a pill, take one as soon as you remember. Then take all others as usual. If you miss two or more pills, take 1 as soon as remembered. Take all the others as usual and in addition use a condom for 7 days. (vi) Injectables Injectables are long acting contraceptives given deep intramuscularly. The three commonly used are Depo-Provera (progestin-only) which is administered every 3 months, Noristerat, administered once every two months and Norigynon (combined oestrogen and progesterone) administered monthly. How injectables work Suppresses ovulation Produces thick cervical mucus which hampers the transport of sperm Thins the endometrium, making implantation less likely Advantages Highly effective in preventing pregnancy Easily reversible It allows the client some privacy to practice birth control discreetly Disadvantages Does not protect against STIs/HIV/AIDS Weight gain May cause some changes in menstrual bleeding, nausea, headache, dizziness, mood changes, etc. Dependant on reliable supply and service provider for timely injections 65 For eligibility, user’s instructions and management of side effects refer to the National Reproductive Health Service Protocols, Ministry of Health. (vii) Norplant Implants Norplants are six small silicon rubber capsules containing synthetic progestin that are inserted under the skin on the side of the upper arm through small incision. Progestin is slowly released into the system and it works up to five years. How Norplant works Thickening and decreasing the amount of cervical mucus, making it more difficult for the sperm to penetrate. Suppression of ovulation Creates a thin endometrium Advantages Long-Term highly effective contraceptive Immediately reversible Low risk of ectopic pregnancy Convenient and easy to use Reduces frequency and pain of sickle cell crisis Disadvantages No protection against STIs/HIV/AIDS Insertion and removal of Norplant implants require a trained service provider because it entails a minor surgical procedure. Possible side effects include amenorrhea and irregular bleeding. 66 (viii) Emergency Contraceptive Pills (ECP) ECP can be used within 120 hours of unprotected sex to prevent unwanted pregnancy. They contain the same hormones used in combined oral contraceptive or progestin-oral contraceptives. They can be special doses taken out of a regular pill pack. Pre-packed ECP e.g. Postinor-2 consists of 2 progestin only pills. It is used in cases of rape, unprotected sex or other emergency situations to prevent pregnancy. ECP is not a substitute for regular contraceptive methods. How ECP Works Depending on when ECP is used during the menstrual cycle, the pill will: Stop the release of an ovum Prevent fertilization of an ovum, or Stop a fertilized ovum from getting attached to the uterus. Advantages It is effective It is simple and easy to use It is the only option available to reduce the risk of pregnancy in circumstances such as rape. Side effects are temporary Disadvantages Does not prevent against STIs/HIV/AIDS Nausea and vomiting may occur Menstrual cycle disturbance. May alter the timing of the next menstrual period. Not meant for repeated use. 67 Sexually Transmitted Infections Sexually transmitted infections (STIs) are infections that are contracted through sexual intercourse. Many adolescents may think they are too young or too sexually inexperienced to acquire STIs. They may also think they are not at risk, because they incorrectly believe that STIs can only occur among people who are promiscuous or who engage in ‘bad’ behaviours. The role of the provider is not just treating adolescents who contract STIs, but to help them learn about prevention. Adolescents are particularly vulnerable to STIs because: They lack information about prevention of STIs They are less likely to seek proper information or treatment due to fear, ignorance, shyness or inexperience For some STIs such as Chlamydia or genital herpes, the risk of contraction is greater at first exposure Adolescent females are more susceptible to infections than older women due to their immature cervices Early sexual experience can result in trauma to vaginal tissue, increasing the adolescent girl’s vulnerability to STI’s Adolescents are more likely to have a greater number of lifetime sexual partners The most common STIs among young people include genital warts, Chlamydia and genital herpes. However, gonorrhoea and syphilis also occur often. Most bacterial STIs like gonorrhoea, Chlamydia and syphilis, are relatively easy to cure with antibiotics if seen early. Viral STIs like genital warts, genital herpes, hepatitis B and HIV/AIDS are incurable, but controllable. Young people need to know symptoms that may indicate they have an STI. These include: Urethral discharge or painful urination in male adolescents Genital sores or ulcers (either painful or painless) Lower abdominal pains or tenderness in female adolescents 68 Vaginal itching or unusual vaginal discharge Painful urination or painful discharge Young people must be counselled to seek early treatment if they have any of these symptoms. Adolescents who contract STIs risk serious long-term health problems such as permanent infertility, chronic pain, cancer of the cervix in females, heart and brain damage. Making Sex Safe-Counselling the Adolescent on What He/She Can Do Abstain from sexual contact (penetrative or touching without penetration). Some STIs include human papilloma virus (HPV), molluscums and chancroid can be spread by touching-either genital to genital or hand to genital-so massage and mutual masturbation can be risky. If the adolescent is already sexually active, he/she can lower risk to STIs by engaging in a monogamous relationship in which both partners make an agreement to be faithful sexually and stick to it. Avoid sexual contact (penetrative or touching without penetration) until he/she is reasonable sure through testing and examination-that both partners are free of STIs. The adolescent must be aware that there are limitations to the value of testing, as latent bacteria and viruses can be present without visual evidence or even positive testing. Use condoms made of latex or polyurethane. While condoms do not provide 100% protection, they do provide the best protection now available. Adolescent girls can also use a vaginal spermicide containing nonoxynol-9 to create an additional barrier against STIs. Girls who feel hesitant about insisting on the use of condoms need to remember that many STIs are more dangerous for them as females because they have fewer obvious symptoms and a higher risk of serious health consequences. Do not use drugs including alcohol, in potentially intimate situations. Drugs inhibit the ability to make good judgement. 69 5.2 SUBSTANCE ABUSE A substance, in this context, is defined as any product that affects the way a person feels, thinks, sees, tastes, smells or behaves when he/she uses it (psychoactive substance). Such substances can be medicine, such as morphine, or an industrial product, such as glue. Some substances are legal, such as approved medicines and cigarettes; others are illegal, such as cannabis, heroine and cocaine. Substance abuse is the use of any mind altering agent to such an extent that it interferes with the individual’s biological, psychological, or socio-cultural integrity. It can be described as an overindulgence in and dependence on an addictive substance especially alcohol or a narcotic drug; or a destructive pattern of substance use leading to clinically significant (social, medical) impairment of distress. Substance abuse involves one or more of the following: Recurrent drug use, resulting in a failure to fulfil major responsibilities at work, school or home. Recurrent drug-related problems Recurrent drug use in situations in which it is physically hazardous, such as before driving. Continued drug use despite persistent social or interpersonal problems caused or exacerbated by the effects of drugs. The pattern of use may be constant or intermittent and physical dependence may or may not be present. Common usage of the term ‘drug’ often refers specifically to psychoactive drugs and even more specifically, to illicit drugs, of which there is non-medical use in addition to medical use. Psychoactive substances/drugs are substances that can alter a person’s consciousness or experience. They include substances like: Alcohol-kill me quick, apketeshie, c-v. spirits, beer, wine Cannabis-wee, marijuana, ganja, international herb, devil weed, abonsam tawa, grass, hashish, bhang. Nicotine-cigarettes, cigars, pipe, chewing tobacco, snuff. Hallucinogens-LSD, Mescaline, psilocybin, peyote, ayahuasca Depressants-sedatives, alcohol, benzodiazepines, barbiturates, chloral hydrate, Librium, ativan 70 Volatile inhalants-aerosol spray, butane gas, petrol/gasoline, glue, paint thinners, solvents, amyls. Stimulants-Amphetamines, cocaine, crack, herbinem morphine, opium, methadone, pethidine Substance abuse can lead to addiction, dependence tolerance and the risk of HIV transmission as well as Hepatitis B and C infections which may be directly related to the route of administration. How Drugs/Substances Affect the Body 1. Alcohol Absorption: When ingested 20% is rapidly absorbed from the stomach into the bloodstream. About 75% is absorbed through the upper part of the small intestine. All alcohol a person consumes is eventually absorbed into the blood. Metabolism: The main site of alcohol metabolism is the liver, though a small amount is metabolized in the stomach. About 2%-10% of ingested alcohol is not metabolized in the liver or other tissues, but is excreted unchanged by the lungs, kidneys, and sweat glands. Immediate Effects: Effects can be felt at blood alcohol consumption (BAC) of about 0.03-0.05%. These effects may include: -light-headedness -relaxation -release of inhibitions -mild euphoria -more sociability -interference with motor coordination, intellectual and verbal performance -irritability 71 When blood alcohol reaches 0.1%. most sensory and motor functions are reduced and many may become sleepy. Vision, smell, taste and hearing at this stage become less acute. At 0.2%, drinkers are completely unable to function because of pronounced depression of the central nervous system, muscles and other body systems. At 0.35%, there is coma. Effects of Alcohol on Body Organs and Systems Central Nervous System (CNS): Impaired reaction to time and motor coordination, impaired judgment and sedation, coma and death at high blood alcohol concentration. Senses: Less acute vision, smell, taste and hearing. Stomach: Nausea, inflammation and bleeding. Skin: flushing, sweating, heat loss, hypothermia, formation of broken capillaries. Sexual functioning: In men reduced erection response. In women reduced vaginal lubrication Brain: Damaged/destroyed brain cells, impaired memory, loss of sensation in limbs, brain atrophy. Cardiovascular system: Weakened heart muscle, elevated blood pressure, irregular heartbeat, increased risk of stroke. Breast: Increased risk of breast cancer. Immune system: lowered resistance to disease. Digestive system: Cirrhosis of the liver, inflammation of the stomach and the pancreas, increased risk of cancers of the lip, mouth, larynx, oesophagus, liver, rectum, stomach and pancreas. Kidney: Kidney failure associated with end-stage liver disease. Nutrient: Nutrient deficiencies, malnutrition. 72 Reproductive system: In men impotence and testicular atrophy. In women, menstrual irregularities and increased risk of having children with foetal alcohol syndrome. Bone: Increased risk of osteoporosis, increased risk of fractures from frequent falls Alcoholics have a cancer rate of about ten times higher than those of the general population. Signs of Alcohol Abuse 1. Drinking alone secretively. 2. Using alcohol deliberately and repeatedly to perform or get through difficult situations. 3. Feeling uncomfortable on certain occasions when alcohol is not available. 4. Escalating alcohol consumption beyond an already established drinking pattern. 5. Getting drunk regularly or more frequently than in the past. 6. Drinking in the morning or at unusual times. 7. They smell of alcohol Tobacco The primary reason why people continue to use tobacco despite the health risk is that they have become addicted to a powerful psychoactive drug: nicotine. All tobacco products contain nicotine and the use of any of them can lead to addiction. Health Hazards of Tobacco Tobacco adversely affects nearly every part of the body including the brain, stomach, lung, mouth, and reproductive organs. Tobacco smoke contains hundreds of damaging chemical substances, including nicotine, acetone, ammonia, hexamine and toluene. Smoke from a typical unfiltered cigarette contains about 5 billion particles per cubic millimetre (50 times as many as are found in an equal volume of 73 smoggy urban air). These particles, when condensed, form a brown sticky mass called cigarette tar. At least 43 chemical in tobacco smoke are linked to the development of cancer. Tobacco also contains poisonous substances including arsenic. Immediate Effects of Smoking The beginner smoker often has symptoms of mild nicotine poisoning including dizziness, faintness, rapid pulse, cold clammy skin and sometimes nausea, vomiting and diarrhoea. Nicotine has many other immediate effects: One the brain (cerebral cortex): it stimulates the release of chemicals that alter mood. Mucous membrane: Tars and toxins irritate mucous membranes and dull taste buds. On the lungs: irritation increases mucous production and damages cilia in the bronchial tubes, allowing particles to reach delicate lung tissue. On the heart: It accelerates heart rate and elevated blood pressure. On Adrenal Glands: It stimulates adrenal glands to release adrenaline, causing changes in functioning of heart and other organs. On the stomach: nicotine depresses hunger contractions. On the Kidneys: Nicotine inhibits production of urine. On the Liver: causes liver to release glycogen, raising blood sugar level. 74 Cumulative Effects of Tobacco These fall into two general categories. The first is reduced life expectancy. A male who takes up smoking before age 15 and continues to smoke is only half as likely to live to age 75 as a male who never smokes. If he inhales deeply, he risks losing a minute of his life for every minute of smoking. The second category involves the quality of life. Smokers spend one-third more time away from their usual life endeavours because of illness than non smokers. Effects of Smoking on the Non Smoker The US Environmental Protection Agency (1993) has designated environmental tobacco smoke (ETS) as a class of carcinogen. Environmental tobacco smoke consists of mainstream smoke and side stream smoke. Smoke exhaled by smokers is referred to as mainstream smoke. Side stream smoke enters the atmosphere from the burning end of the cigarette. Undiluted side stream smoke, because it is not filtered through either a cigarette filter or a smokers’ lungs, has significantly higher concentrations of toxic and carcinogenic compounds found in mainstream smoke. Side stream smoke has twice as much tar and nicotine, three times as much benzopyrene (a carcinogen), almost 3 times as much carbon monoxide and three times as much ammonia. Nearly 85% of the smoke in a room where someone is smoking comes from side stream smoke. Studies show that up to 25% of non smokers subjected to environmental tobacco smoke develop coughs. 30% develop headaches and nasal discomfort and 70% suffer from eye irritation. Other symptoms range from breathlessness to sinus problems. People who live, work or socialize among smokers face a 24-50% increase in lung cancer risk. Non smokers can still be affected by the harmful effects of environmental tobacco smoke hours after they have left a smoky environment. Carbon monoxide for example, lingers in the bloodstream five hours later. 75 The adolescent needs to learn strategies for avoiding environmental tobacco smoke (ETS) to keep the air around him or her safe: Avoid hanging out with other adolescents who smoke, apart from the bad effects of ETS, you might also pick up the habit. Speak up tactfully-try something like “would you mind putting your cigarette out or moving to another spot? The smoke is bothering me.” Display reminders around you. Put up signs asking smokers to refrain from smoking in your room, work area, etc. Do not allow smoking in your home or room. Get rid of ashtrays and ask smokers to light up outside. Open a window. If you cannot avoid being in a room with a smoker, try to provide some ventilation. Sit in non smoking areas in restaurants and other public places. Complain to the manager if none exists. How to Quit Smoking Counsellors can assist smokers to stop by giving some suggestions like: 1. Throw away your tobacco. Do not keep any in your pockets, car, classroom, dormitory, or house. 2. Keep yourself busy or occupied. Find something to do with your hands. Work at a hobby. 3. Drink lots of fluids, preferably water and fresh fruits. 4. Have enough sleep. Go to bed early and rise early. Drink a cup or two of clean water on rising. 5. Start a good exercise programme. Walking is a safe exercise. 6. Inform all friends about what you are trying to do: that you are trying to quit smoking-they may assist. 7. Try to mix with non smokers and non drinkers. 8. Do not blame yourself if you slip. Start again. When the urge becomes unbearable, do something that makes smoking practically impossible. 9. Visit a friend who can give you support at this time. 76 Benefits of Quitting Smoking Within twenty minutes of your last cigarette You stop polluting the air Blood pressure drops to normal Pulse rate drops to normal Temperature of hands and feet increase to normal. After 8 hours: Carbon monoxide level in your blood drops to normal Oxygen level in blood increases to normal After 24 hours: Chance of heart attack decreases After 2-3 months: Circulation improves Lung function increases up to 30% Walking becomes easier. After 1-9 months Coughing, sinus congestion, fatigue and shortness of breath all decrease Cilia re-grow in lungs, reducing chances of infection After 1 year: Heart disease and death rate is half that of a smoker After 5 years: Stroke risk drops nearly to the risk for non smokers After 10 years: Lung cancer death rate drops to 50% of that of continuing smokers The incidence of other cancers (mouth, throat, larynx, oesophagus, bladder, kidney and pancreas) decreases. After 15 years 77 Risk of lung cancer is about 25% of that of continuing smokers. Risk of heart disease and stroke are the same as for non-smokers. 5.3 ENVIRONMENTAL HEALTH AND SANITATION. The way that people live has a continuous effect on the physical environment. As life-styles change, some health hazards are controlled or eliminated, while new ones are generated. The relationship between environment and health must be seen in this dynamic context. Hence environmental health involves good and adequate sanitation and prevention of the occurrence and spread of disease in a community. Thus, the objective is to provide a healthy environment which forms a preventive measure to control a variety of diseases which may be grouped as: 1. Water-borne diseases (Dysenteries, Typhoid etc) 2. Air-borne diseases (Pulmonary tuberculosis, measles, cerebro spinal meningitis etc). 3. Food-borne diseases (Worm infestation, cholera etc.) 4. Insect-borne diseases (Yellow fever, malaria, onchocerciasis etc). 5. Diseases associated with bad housing. Nevertheless, healthy environment could be achieved through provision of the following amenities; a. Safe and adequate water supply. b. Good system for disposal of both dry and wet refuse. c. Proper food hygiene. d. Good housing. e. Control of insect vectors and other pests. A. WATER SUPPLY Water is a basic human need next to food. Similarly, water is an important determinant for health. The human body needs at least three (3) beer bottles or 2 litres of water each day for it to function properly. However, in the home, large volumes of water is needed daily for all the needs of human beings. 78 The common sources from which water can be obtained include, pipe borne, wells, ponds, streams, rivers, lakes, springs etc. Yet the existence of water-point is no guarantee in itself that water will always be available and safe. Similarly, water-point requires drainage; otherwise the provision of water can have adverse health effects. In the absence of a water-point in the household, other alternatives are; stand pipe or protected well within walking distance. In recent years, the water supply in Ghana is often beset with problems such as irregular supply and non safety of the water. Water can be made safe by the following means, such as boiling, filtration or sieving and chemical sterilization. It is worthy to note that in the home, water should be stored in clean pots or containers with well fitting covers. This is to prevent contamination by dust, dirt etc. Adolescents in schools are fond of using the same cup or bottle from one person to the other, thus encouraging cross-infection. Shortages of water in the country have given rise to manufacturing of mineral water in sachets and bottles. However, not all mineral water is safe and adolescents should inspect the water whether it contains particles, discoloured or it has awful taste. B. DISPOSAL OF SOLID AND LIQUID WASTE The accumulation of waste matter such as dry refuse endangers health because it allows breeding of rodents and pests such as flies, cockroaches, mice and rats. These wastes can lead to outbreaks of diarrhoeal diseases and plagues. Indiscriminate throwing of dry refuse such as garbage, rubbish, ashes, and dead animals must be stopped as it makes the environment unsightly. Adolescents should make efforts to put refuse into thrash cans or dust bins instead of littering refuse in their environment. For example, waste from sachet water is creating tons of waste around the big cities and it is also an eye sore to see people selling foods near refuse dumps or choked gutters. Wet refuse includes human excreta (faeces and urine) and waste water from kitchen, bathroom, factories, public drains and gutters. There are various methods of disposal of sewage such as pit latrines, Kumasi Ventilated Improved Pit Latrines (KVIP), conservancy system, septic tank latrines (Aqua 79 privy) and water closets. Unfortunately, these effluents are rather discharged into streams, lagoons and sea. Such practice will contaminate the water sources and fishes and eventually killing the water bodies. These practices can lead to food poisoning, air borne diseases such as respiratory diseases. Adolescents must adopt hygienic practices and should not defecate or urinate into gutters, on the beaches or anywhere. Parents and school authorities should ensure that there are adequate numbers of toilets and the adolescents should use them properly. C. FOOD HYGIENE Food hygiene is a process where food is kept free from contamination. It also prevents spoilage. Although food is essential for survival of man, it can also be a source of food borne infections and diseases such as food poisoning and worm infestation. Food hygiene therefore ensures that food which reaches the consumer is clean and safe. This involves everyone in contact with food, that is, the producer, manufacturer, distributor, retailer and consumer. The main measure in ensuring food hygiene is through education. Thus, this should be a concerted effort. Food can be contaminated from the following stages: preparation, cooking or serving periods. It can also be contaminated from the farms, transportation, market, kitchen and lastly, food handlers and consumers. Unhygienic Methods of Food Handling a) Selling cooked food in the open air, near public refuse dumps, latrines and choked gutters. b) Selling raw foodstuffs, vegetables and fruits on the ground and dirty surroundings. c) Cooking with dirty hands and long dirty nails. d) Coughing, sneezing and talking into food. e) Blowing air into polythene bags before putting in food, such as gari and sugar etc. f) Exposing food to dust, flies, rodents and vermin such as rats and mice. g) Cooking in dirty kitchen or compound. h) An infected person cooking or handling food like typhoid carriers. i) Dishing and serving food into dirty or chipped plates or using contaminated serving spoons as well as leaves, newspapers, cement papers etc. j) Public premises of food not inspected like slaughter houses, restaurants, hotels, schools etc. k) Strict adherence of hand washing being overlooked. 80 School authorities should ensure that food vendors on their school compounds would have regular medical check-ups and strict hygienic practices. In the same vein, the school feeding programmes should also observe cleanliness. Clothes should be clean and hair covered. The premises must be clean and maintained very well to deter insects, rodents and vermin. Food should not be served in chipped plates as they harbour germs, leaves, newspaper, cement paper etc. Parents and school authorities should instil into adolescents strict hygienic practices. In addition, fresh fruits and vegetables should be washed thoroughly well before eating. Dangers of Unhygienic Foods Unhygienic foods can be easily contaminated with germs which can cause diarrhoeal diseases, cholera, typhoid, dysentery and worm infestations. D HOUSING The physical environment begins with the house where the health risks are manifold. The house in which a person lives has an important influence upon his/her health either for good or bad. They stem from factors related to the structure, materials, design and available space. Housing of poor quality often fails to protect people against heat, cold, wind, rain and disease – carrying insects and rodents. In the slum areas and shanty settlements, overcrowding is common resulting in skin infections such as ringworm, impetigo, scabies and even lice infestation. Inadequate ventilation and overcrowding will result in spread of respiratory diseases, tuberculosis and meningitis while congestion in the houses will result in lack of privacy. Therefore adolescents are exposed to sexual activities of their parents or there is lack of parental control leading to upsurge of teenage pregnancies and its accompanying hazards. Lastly, the over congestion in the houses may lead to home accidents such as burns, scalds, fractures etc. There are types of houses such as temporal, semi-permanent and permanent. 81 1. Factors to Consider When Putting Up a House A good house should be:- i) Well sited. It should not be in a low-lying land, which is subject to flooding. The land should not be swampy as this encourages mosquito breeding and diseases like rheumatism and chest diseases. ii) Well Structured a) Every house must have a plan and build accordingly to it. . b) The building materials used should be of good quality, e.g. sand, stone, burnt bricks, cement etc. c) There should be good foundation formed with stones and concrete. d) The roof should have a ceiling to prevent excess heat from entering rooms. e) The rooms should be enough for the members of the family and spacious to prevent over- crowding. f) The doors and hinges should be good so that they do not fall off and cause home accidents or are easily broken into by thieves. iii) Other Amenities There should be: a) Availability of portable water supply. b) Availability of safe playing ground for the children. c) Kitchen, toilet and bathroom. 82 d) Proper drainage system. e) Good storage facilities. f) Good storage, ventilation, lighting system, good refuse disposal facilities. g) Enough land for gardening. h) Burglar proof for security. i) 2) Mosquito Netting. Care of the House A well-designed house can become unsanitary, if it is allowed to get dirty, or infected with rodents, or fall into despair. It is the responsibility of the owner to keep the main structure in good repair. The family living in the house must keep it clean, tidy and in good order. Failure to do this can be dangerous to health. The area council has the right to declare the house unfit for habitation if it is overcrowded or falling apart. Repairs and maintenance on the house must be done from time to time. i) Cleanliness of the House a) Inmates including adolescents must keep the house as clean as possible. Weeds must be cleared, stagnant water drained and gutters cleaned. b) Rooms must be swept and dusted to keep them clean from dust and dirt. c) Kitchen, latrines, bathrooms and hand washing basins must be kept clean to prevent breeding of flies, cockroaches, mosquitoes and to avoid the dangers of food poisoning. d) All garbage (foodstuff peels or fruit skins) must he quickly disposed or covered up. e) Used utensils must be washed up quickly. If they are left unwashed for long hours, flies will be attracted casing nuisance. f) Refrigerators and deep freezers if any must be cleaned from time to time. g) Animal pens must be fenced and kept further away from the main house, possibly the backyard. h) Each family must maintain its house and surroundings in healthy state. 83 ii) Problems Associated with Poor Housing 1) Respiratory/Chest diseases like pneumonia, tuberculosis (TB) colds, asthma etc. 2) Malaria due to mosquito breeding as a result of stagnant waters. 3) Rodents, cockroaches, worms and flies infestation due to improper disposal of refuse which can lead to gastro-enteritis, food poisoning, typhoid fever etc. 4) Home accidents may be common due to poor construction of the building e.g. falls, burns etc. 5) Overcrowding resulting in mental stress/ breakdowns and spread of communicable diseases such as tuberculosis (TB), meningitis, skin infections i.e. scabies etc. 6) Children/Adolescents becoming wayward, teenage pregnancy etc due to lack of space, privacy and overcrowding. 5.4 PERSONAL HYGIENE Hygiene can be defined as a science of health and its maintenance, personal hygiene is the care that people themselves take in regard to health. Hygiene is a highly personal matter attached to the individual values and practices. It is influenced by cultural, social, familial and individual factors, as well as by the person’s knowledge level of health and hygiene, perceptions of personal comfort and needs as well as developmental status. Adolescents may or may not be aware of their individual needs. Adolescents need to pay particular attention to personal hygiene. Cleanliness promotes a feeling of well-being and self-respect. Hygiene practices involve care of the skin, hair, nails, teeth, perineal and genital areas and control of body odours and the use of cosmetics. Keeping the body clean contribute to physical, mental and social well-being as well as protection against infection and illness. 84 Skin Care Basic maintenance of the skin is important because it keeps the skin healthy and protects it from damage. It contributes to the prevention of a number of skin conditions including dryness, wrinkles, liver spots and skin cancer. Most adolescents are very active and therefore may sweat a lot because of the hot weather. Thus, it is very important for the adolescent to pay more attention to his/her appearance and body odours. The skin covers most parts of the body and plays a very important part in the elimination of waste. Daily washing of skin with natural soap and water gives protection against infection. However, adolescents with oily skin, those who perspire a lot or those who live in warm or humid climates may benefit from bathing twice a day. Use of the local black soap for skincare is the best choice to make. Whether one washes with hot or cold water depends on age, resources and the health of the individual as well as the purpose of the bath. Bathing sponges, back brushes and heel scrubbers are available. The use of lime or lemon in the armpit helps to clear bad odours. In addition, the use of natural deodorants and antiperspirants and perfumes take away unpleasant odours. However, they must be used in moderation as some individuals may be allergic to some of them especially, those suffering from asthma. The use of corrosive or abrasive substances or bleaching of the skin makes the skin more vulnerable to infection and even skin cancer. Tattoos and piercing also increase the adolescent’s risk to infection such as HIV / AIDS and Hepatitis B through the use of contaminated cutting or piercing instruments. It is also important to shave any unsightly hairs from the armpit as well as the genital area, as these areas harbour germs (microorganisms). Adolescents with certain skin conditions or problems for example, acne (pimples) and eczema require special soaps and skin products or care of skin specialists. It is important for each adolescent to have his or her own towel and sponge to prevent cross infection. Hair Care The hair needs regular attention. How often the hair should be washed depends on the type of hair – thick or thin, dry or oily, long or short, environmental condition, whether one lives in a dusty industrial area or in a clean unpolluted area with or without adequate water supply; climate situation – whether hot or cold, dry, humid or dusty and on the individual’s occupation. Hair must be washed regularly with 85 soap or shampoo to remove dirt and grease from creams and oil frequently used on hair. Avoid shampoos with borax or alkalis. Use of the local black soap for hair is the best choice to make. Rinse hair well. Dry the hair after a wash. Proper care of the hair will prevent dandruff and also lice infestation. Lice may spread typhus fever. Combing and brushing serve as means of exercising the scalp as well as allowing free circulation of air on the scalp. In addition to general cleanliness there are other ways of caring for ones hair thus plaiting and weaving. Use of chemicals cause allergic reactions such as scalp allergies, allergic colds and throat conditions. Any hairstyle should enhance his/her appearance and the young person should act in modesty. The hairstyle or cut usually, depends on the individual’s interest, skill and taste. If possible the adolescent should avoid any fanciful haircut. A clean hair looks very lustrous and attractive, raises morale and instils confidence. Care of Hands Cleanliness of the hands is essential in promoting health and preventing ill health caused by conditions such as diarrhoeal diseases (Gastro-enteritis) and intestinal worms. The hands need special attention because they can be a real source of infection from one person to another. Thus, it is important to wash hands thoroughly with soap and water before and after every meal, after visiting the toilet, after changing sanitary pads, after playing, gardening and handling garbage. Soaping and rinsing should cover the areas between fingers, nails and back of the hands. The hands should be dried with clean hand towel, handkerchief, tissue or electric drier. Individuals can also use an alcohol-based hand sanitizer to clean their hands when soap and water is not available. However, soap and water is essential because water alone cannot remove the dirt effectively from the hands. Our local black soap is a good option. The use of good hand lotion or barrier creams help to keep the hands clean, smooth and chap-free all the time. Shea butter, palm kernel oil and coconut oil are natural oils for the skin, hands and feet. 86 Nails A healthy body ensures healthy nails. Brittle or discoloured nails indicate deficiencies or disease conditions. Long nails may harbour germs (micro-organisms) eggs of worms which can cause diseases. Nails must be trimmed and cut short with scissors but do not cut them so close that it pinches the skin. Do not keep your nails painted continuously. It causes the keratin of which nails are made to spilt. Beautifully shaped, well-groomed hands are pleasing. Foot Care The adolescent should pay attention to his/her feet. The feet should be washed with soap and warm water. This has a soothing effect. Efforts should be made to keep in between toes dry. Shoes should be comfortable and not tight to prevent corns. If socks or stockings would be worn they should be changed frequently. The shoes should be aired in the sun regularly. Occasional massages of the feet improve circulation to the extremities. This could be done by scrubbing with a sponge, pumice stone or foot scrubber. Go for a pedicure once in three weeks. Infection can lead to foot rot. Mouth Care Regular cleansing of the mouth and teeth is important at all times in maintaining perfect health. The adolescent should be encouraged to clean his/her teeth at least every night and morning as well as after each meal. It is necessary to pay regular visit to the dentist at least twice a year. If possible avoid overeating of sweets and avoid smoking. The cleansing materials used in different societies differ. Some are purely cleansing while others are both cleansing and medical e.g. chewing sponge or chewing stick and the medicated toothpaste that contains fluoride. Clean all sides of each tooth, paying particular attention to a few teeth at a time. Move the brush, chewing stick or sponge up and down the teeth. Remove the food particles between the teeth with a tooth pick and dental floss. Any neglect will lead to gum diseases, dental caries or tooth decay and bad breath. 87 Habits and practices that can harm the teeth; - Sharpening or filing the teeth to make them pointed or to create artificial spaces removes enamel. - Making a hole in the upper lip and inserting an ornamental stick or ring in it, as is done in some societies, interferes with the action of the upper lip and therefore with speech. It may also injure the gums. - Removing bottle tops, cutting ropes and biting hard foods with the teeth may cause the teeth to break or make them loose. Clothing The amount and kind of clothing to be worn depends a lot on the climate and season. The clothes an individual wears greatly influence the impression he/she makes on others and his/her social acceptance in general. Clothing should be warm enough to comfort and sufficiently loose to allow free circulation of air and movement of the limbs. Frequent changing of clothes will remove body odours. Cotton clothes are more suitable for the tropics. Underwears (e.g. pants, singlets, brassier etc) are worn next to the skin, they should be washed daily. Menstrual Hygiene (Female Adolescents). The female adolescent should keep herself clean during her menstrual period. Materials used such as sanitary pads or tampons should be changed frequently, at most every three hours. They should be properly wrapped and disposed off in the trash can or dustbin. If panties or clothes get stained with blood they should be washed with cold, mildly salty water. Keep the perineal area dry. Adolescents have to wash their hands before and after changing their sanitary pads. Parents should provide adequate sanitary towels, privacy and disposal facilities for adolescent girls. Adolescent girls should bath regularly during menstruation and wash the vagina area. Avoid cleaning the vagina with lime or any other chemical. 88 5. 5 PRE-CONCEPTION MANAGEMENT The concept of adolescence has been variously defined as the state or process of growing up or the period of life from puberty to maturity. It is understood in different ways in different cultural contexts. Almost universally, however, it is seen as a time of transition between childhood and adulthood, a period of physical and psychological changes associated with puberty and of preparation for the roles, privileges and responsibilities of adulthood. The nature and experience of adolescence vary tremendously by sex, marital status, class, geographical area (rural or urban) and cultural context. As already mentioned in Chapter one, the WHO defines adolescence as persons between 10 – 19 years. However age variations that are of importance are as follows: Pre-adolescents 5-9 years Younger adolescents 10-14 years Older adolescents 15-19 years Youth 15-24 years Youth Adults 20-24 years Thus, there is over lapping between these categories. As a group, however, adolescents are generally recognized to have sexual and reproductive health needs that differ from those of adults and which are still poorly understood in most parts of the country. The diagram below depicts the ideal pre-conception cycle of care useful for adolescents. 89 THE PRECONCEPTION CYCLE OF CARE 1. Weight and height 15. Sub fertility 2. Nutrition 14..Family Planning 3. General Check-Ups 13..Psychosexual counselling 3a. Urine test HEALTHY 3b. Stool test CONCEPTION 12..Environmental pollutants 3c.Blood Pressure check 11. Immunization 3d. Breast Examination 4. Pre-marital sex avoidance 10.Genetic counselling 5. Social poisons avoidance 9. Medications 8. Blood tests 6. Ovulation and the menstrual cycle 7. Exercise and relaxation 90 The parameters of preconception cycle of care are depicted in diagrammatic form above. Some basic issues arising are in table 1 below: ELEMENT COMMENTS Weight and height Body mass index of less than 20 score can result in sub-fertility, the birth of a mentally subnormal baby, small for age babies or aborted foetuses. Nutrition Pre-conception nutritional status can prevent anaemia which can cause mental retardation of a child born to a woman with anaemia in pregnancy and may hasten the woman’s death should a post partum haemorrhage occur. General Check ups These tests can help identify diabetes, UTIs, worms especially hookworms. Stool examination may also help with detection of mal-absorption. Breast self examination and Blood pressure checks are helpful to detect breast cancers and hypertension. Pre-marital sex avoidance Helps to reduce STI/HIV and AIDS. Half of all new HIV infections are in young people. For the sexually active woman a papanicolau (PAP) smear for the early detection of abnormal cells/cancer of the cervix is advisable. Social Poisons They include alcohol, tobacco, cigarette smoking and drug addiction. They may harm unborn babies. Foetal malformation, abortion, failure to thrive and foetal alcohol syndrome may result Ovulation and menstrual cycle Knowledge about this can help to plan pregnancy or avoid it. It may also help with correct calculation of the expected date of delivery Exercise and relaxation Regular moderate exercises in fresh air improves health, weight and fitness and helps with relaxation. Strenuous exercises may cause stress on reproductive organs and lead to difficulty in child bearing, spontaneous abortion, premature labour and foetal malformation and excessive bleeding after delivery. Table 1 Management The management of sexual and reproductive health of the young starts from the pre-adolescent age i.e. 5-9 years, as there is early onset of menarche in recent years. Thus, during their school lives, family life education should be taught seriously for them to be familiar with the physical, psychological and emotional changes that are taking place. 91 Education Programs Special Educational programs should be organised for young people to educate then on sexual and reproductive health issues as well as nutrition. IEC materials should be available and easily accessible to them. Functional education should be encouraged. Health Screening It is necessary for would-be couples to seek specific attention before embarking on pregnancy. Basic Check-up a. History and Physical Examination Time should be allowed for relaxed discussion about life-styles, dietary habits, alcohol use, smoking and possible exposure to hazards. A full medical history must be taken from the wouldbe partners. Each should have thorough physical examinations including measurement of height, weight and blood pressure. The Body Mass Index (BMI) should be checked regularly before pregnancy. BMI is a method of calculating the ideal pre-pregnancy weight. This is achieved by checking the height in metres and weight in kilograms of the client. Multiply the height by height, i.e. height in metres square. Then divide the weight in kilograms by the height in metres square. For example Weight -52 kilograms Height-1.6 metres x 1.6 metres Formula- 52/2.56 BMI = 20.3 Thus the following BMI have different interpretations. Less than 20 means underweight 92 20-24.9 desirable or just right for pregnancy 25-29.0 moderate obesity Over 30- severe obesity A reproductive health history including menstrual history should also be taken to determine whether it is regular or irregular. A gynaecological examination is necessary to exclude vaginal infection or sexually transmitted infections. b. Blood Investigations Blood examinations should be done to determine blood group or type, check Rhesus factor status and if negative, the antibody levels should be known. Sickling tests should be done and in case it is positive electrophoresis should be done. Venereal Disease Reference Laboratory (VDRL) test should be done to rule out syphilis. If possible, voluntary Counselling and Testing for HIV should be done to determine the HIV status of the partners. Tests should be done for Rubella and Hepatitis to ascertain the antibodies level. c. Drug history There should also be thorough drug history so that any medical condition could be stabilized e.g. epilepsy, diabetes, allergies and sensitivity to drugs. d. Genetic Counselling It is important to seek genetic counselling if aged 35 or older or if there is any history of familiar diseases such as hypertension, diabetes, sickle cell and cancer etc. This is done to rule out any hereditary factor. Some couples may opt to avoid having children altogether since there are higher chances of giving birth to syndromic children with congenital malformation such as Down’s syndrome, hole in heart etc. e. Service Delivery There should be no barriers to accessibility of youth-friendly health services such as physical, economic or cultural. Adolescents are entitled to a full range of health services including reproductive health especially for all sexually active adolescents. Both boys and girls will 93 receive specific services to meet their peculiar needs. The services should include general health services, contraceptive services, sexually transmitted infection management as well as management of sexual abuse. Promotive, preventive, curative and rehabilitative health services are essential. Adolescents should be immunized against certain diseases according to their antibodies levels such as tetanus, hepatitis B & C and German measles (Rubella) and others based on country specific practices. 94 CHAPTER SIX: RELATIONSHIPS Effective Relationships One of the main tasks of adolescents is to learn to relate effectively with peer of the same and opposite sex. This becomes the basis for adult relationships including marital relationships. To relate well with others one needs both knowledge and practice. Information that is needed includes how to initiate relationships, how to listen effectively to others and how to communicate thoughts, feelings and needs to minimize and resolve conflict. Initiating Relationships Many adolescents find it difficult to walk up to someone they have not talked to before and start a conversation. Usually it is because they are afraid; for example, they are afraid the person will not want to talk to them and they will be embarrassed, or they will not know what to say and feel awkward or the person will misinterpret their interest or that their past experience with people who did not like them will be repeated. The result is that they keep to themselves and wait for someone to come to talk to them. However, since others also may feel the same way, nobody makes a move. The truth is, most people are flattered if another person takes an interest in them and respond positively. Moreover, if a few people do not reciprocate one’s interest it is their loss and there are many who will appreciate the gift of one’s interest. How to Initiate Relationship v. Offer to others what you will like them to offer to you such as respect, liking, interest, openness, etc vi. Focus your attention on the other person and not on yourself. vii. Let your non-verbal behaviour also communicate your interest, for example, smile, move closer to the person until you are at a comfortable distance for a conversation, look at the person’s face as you talk etc. viii. Start talking and say something to invite a response. Any safe topic will do e.g. weather, school, church, football, information about exams etc. 95 ix. Learn to ask questions, especially open ended questions that allow the other person to share ideas, Information: What do you think about………..? How do you feel concerning…………..? What happened……….? Listening Effectively In order to relate well with others, it is important to learn to listen attentively to them and to indicate so to them. In normal conversation, most people are too busy thinking about what they will say next, or what advice to give or how to win what argument etc. to really listen. When people feel you are not listening to them, they get bored and lose interest in relating to you. If you are a good listener others are attracted to you and confide in you. How to Listen 1. Give your whole attention to the person you are listening to and use your body language to let them know this-smile, nod, look at the person, lean towards him or her. Use continuation responses such as -go on, I see, etc to let them continue talking. 2. Let the other person know that you understand what they are saying by periodically checking with them to see if you have understood what they are trying to tell you. 3. Notice their feelings and talk to them about what you notice. For example: I realize what happened made you very angry; I see you are feeling very sad, etc. 4. Ask questions to help you understand better. Use open ended questions. (See page one). 96 Communicating Thoughts, Feelings, and Needs It is not enough just to listen. It is important to let other people know one’s thoughts, feelings, and needs. Many people are afraid of being rejected, hurt or misunderstood and therefore keep their thoughts, feeling, and needs to themselves. Others assume their feelings and needs should be obvious to those they relate to and make no attempt to communicate them. This results in misunderstanding and poor relationships. How much we say about ourselves depends on who we are talking to. With people we have just met or do not know well, we usually talk generally. As we get to know others better, we need to be able to share what we think, how we feel and what our needs are. Talking about such things is not easy for many people. It involves trusting the other person to keep the details to your life you share with to themselves and not gossiping about you. That is why it is a good policy to have a few very close friends you share very personal feelings and needs with, while you share general ideas and feelings and needs that are not so personal with others. How to Communicate about Yourself: 1. Start with your opinions and ideas about general things and move to more personal feelings and needs. 2. Express your beliefs and opinions about issues, people, and situation. 3. Express your feelings. Be aware of the difference between thoughts and feelings. “I feel that you will help me” have little to do with feelings but says something about one’s belief. “I feel sad or angry or frustrated” deals with feelings. 4. Express your needs. Nobody knows what you want unless you tell them. Be as clear as possible when you share your needs. Do not give indirect messages. Instead of “I’d like to borrow a cup of gari. I will replace it when my parents send me provisions” do not say, “Hmmm, I haven’t eaten all day” and look longingly at the gari container. 97 Serious Intimate Relationship Before embarking on intimate relationship, ask yourself the following questions in these areas:Enjoy – Do you and your would-be partner enjoy the same things? May be it is no big deal now, but later when he is glued to the television and you want a little conversation – it will become a problem. Values – Can two people walk together without agreeing? Are you able to agree on child raising, finances, in-laws, goals and your relationship with God? Accessibility – Are you both emotionally accessible, or is he the silent type who does not communicate or understand you?. Love – Do you really love each other? Not the Hollywood version, but the kind that listens to your partner’s opinions and concerns? Overlooks their faults and failings? Values them? Expresses itself through kindness. Understanding – you will not agree on everything, but can you understand and handle each other’s point of view? Appreciation – Appreciation is like an insurance policy, it has to be renewed every now and then. Do you make it a habit of expressing yours? Temperament – Are your personalities compatible? If you are naturally upbeat but they are moody and introverted, you may have oil and water mix. Environment – If you are from different backgrounds, are you comfortable in the same spiritual and social settings? Before you tie the knot – think carefully about these things. Minimizing and Resolving Conflict 98 Identify what the problem really is. Talk about how you feel about the problem but do not attack the other person/people. Talk about what can be done to solve the problem. There is usually more than one way of resolving an issue and there is usually a need for some compromise. It is important to show you are willing to resolve the problem rather than prove you are right. In some cases, for example where the other person is not willing to talk or is very aggressive, it may help if a respected member of the community or religious group is asked to help resolve the conflict. Some conflicts arise out of differences in beliefs, values and personalities. These are difficult to deal with. However, one can learn to live peacefully with people one disagrees with. To do this, an adolescent has to: Remember that people differ Learn to accept them as they are. Know that each person has some goodness that can be approved of. Put our self in other people’s shoes to understand them better. Forgive, for the sake of one’s own mental health as well as for the sake of peace. Wrong Ways of Dealing with Conflict Avoiding talking about it - This results in conflicts building up until often there is a “blow up”. Yielding all the time - Eventually one gets resentful and bitter especially if one is taken for granted. Wanting to win all the time - Makes the other person defensive and ready to fight. Even if you win, it usually results in a break up of the relationship. Remember – it is not enough to have this information it must be put into practice. Dealing with Romantic Relationship Before puberty there is not much excitement in the relationship between the sexes. Children of the same sex tend to club together and when they relate to the opposite sex it is likely to be in a 99 similar fashion as to the same sex. All these changes occur during puberty and after. As part of this process of becoming biologically able to have children, hormone secreted by the body results in a strong attraction towards members of the opposite sex. The desire to be in a special relationship with a member of the opposite sex grows and is the basis of the pairing of to boyfriend/girlfriend couples that often starts during the adolescent years. Adolescents who are socially adapt and able to initiate relationships are more comfortable relating to peers and members of the opposite sex. Those who are shy and withdrawn have more problems with this. The first part of this chapter will be helpful in becoming more comfortable with relationships with others of the same and opposite sex. The desire to have sex generally and especially with someone of the opposite sex you are attracted to is also part of this process. During the adolescent years and young adulthood stage (early twenties) most people are at the peak of their tendency to be sexually aroused. When sexually aroused it is not easy to stop progression actual sexual relations unless one has learned to control sexual desire. The fact that one is sexually aroused does not mean that one should automatically have sex with whoever aroused the desire. This is immaturity and may result in breaking the law concerning rape, defilement, sexual harassment etc. Sexual desire and arousal can be controlled even in intimate relationships in order to do so here are some guidelines: o Relate in groups. Concentrate on friendships and do not centre on only one person unless you are courting and expect to be married soon. This is because regular intense interactions build intimacy both physically and emotionally which makes it more difficult to postpone sex. Moreover there is so much fun and experience in relating to people of the opposite sex that will be missed if you concentrate on one person too soon. o Respect your body, it is unique. There is only one of it in the entire world. Be proud of it and do not allow others to touch you in ways that create sexual arousal frivolously. Breasts, sexual organs or other sensitive parts of your body should be out of bounds unless you want sex. Rules as to what not to do are best made by you. You know yourself best. o Do not get into situations that are tempting e.g. visiting in bedrooms or parked cars. You cannot put your head in a lion’s mouth and not expect it to bite it. It will! 100 o When sexually aroused use your thoughts to calm yourself down e.g. if I do not have sex nothing will happen to me expect a little discomfort. Love the tempting situation as soon as possible. o Talk to your special friend about limits to sexual expression that you want to observe and arrive at rules you both are willing to observe. Remember you are always free to leave the relationship if you cannot agree on your values. o Invest your energies wisely in other activities. This is called sublimation. Studying, hobbies belonging to good clubs and fellowships all help. o You are important and worthy of attention and love. Remember you are God’s child, loved and with gifts. Do not belittle yourself. You do not need peer approval or approval from your boyfriend/girlfriend before you feel good about yourself. o If despite all these you still decide to have sex IT IS IMPORTANT THAT YOU USE A CONDOM AND PROTECT YOURSELF AND YOUR PATNER FROM HIV/STIs AND PREGNANCY. IT IS A MATTER OF LIFE AND DEATH. It is important to note that the attraction towards the opposite sex and the physical and psychological excitement that accompany it are all very normal and should not be rejected just because of fear of becoming sexual too early. What is needed is to learn to relate positively to members of the opposite sex. Tips for a Positive Relationship o Think of fun things to do together with your opposite sex e.g. play a game, go for walks, read a book together and discuss it etc. o Learn to share your ideas with your friends of the opposite sex. Remember that they may not agree with everything you say. Learn to respect their views also without conflict (see section on resolving conflict). Do not try to dominate others just to feel good about yourself. o Respect members of the opposite sex as also important intelligent and worth knowing. Get to know them as individuals. Do not generalize your opinions about them e.g. all girls want money, all boys want sex etc. o Encourage your friends to grow and develop better in all ways, spiritually, emotionally, intellectually etc. Ask yourself am I my friends better people because of our friend. o Enjoy your special friendships and the romantic feelings they generate but remember that this does not mean you are ready for marriage and a responsible sex life. The guidelines below will help you decide if you are ready to start counting it. Relating to a person of the opposite sex with the intention of marrying them soon. 101 Marriage Preparation for Adolescents Marriage as an institution for all human beings is a vital activity for all adolescents who are of age, and are ready to marry. Since the official age is 18years most adolescents, it is certain will start giving it a thought as they mature. Adolescents who are ready can be prepared for marriage. If adolescents must marry then adolescent preparation for pre-marital counselling starts at age 17 years when they learn about friendship, how effective relationship can help in decision making. The marriage preparation is the mechanism that assists them to have a solid foundation in marriage. It is therefore essential to give pre-marital preparation and then pre-marital counselling if the adolescents have made choices through friendship and courtship and have agreed to marry. It is normal when adolescents during pre-marital counselling fall out because they are incompatible. Here the counsellor should respect their decision and allow them to separate. If on the other hand, the adolescent couple has decided to marry on negative grounds, this should be discussed fully and appropriate steps taken. The couple should have a fair idea of what is happening between them and decision is accepted or honoured by the couple. They are not enemies but they have made a final decision that will be beneficial to both now and in future. Understanding and love should be a working tool and guide them appropriately (give appropriate guidance). The adolescent couple that had thoroughly been prepared for marriage counselling with all seriousness. Guidance and healthy education on pre-marital counselling should be given. Selected topics which would be beneficial should be discussed and explained and adolescents made aware of what marriage really entails. All conditions pertaining to marriage should be fulfilled and steps taken to educate the would-be adolescent couple to work towards a lasting fulfilling marriage. The preparation also helps them to study friends closely to know their likes and dislikes before a meaningful and final choice is made. All adolescents should be encouraged to pass through the preparation stage to enhance wise choices and fruitful decision. As counselling is a process which helps adolescents to know themselves, their environment and methods of handling their 102 roles in relationships they establish, they should endeavour to seek a better understanding of themselves from a trained person who can handle the situation carefully and firmly. Parents, older adults, church/religious leaders should provide needed information at all times for a better adjustment from childhood to adulthood. In some Ghanaian cultures, custom demands that adolescents are prepared through puberty rites until they enter adulthood. Traditional education is passed on from generation to generation. It is imperative and even desirable that we support and make the practice operative. Enlightened guidance from the traditional authorities and the elderly in the different cultures in the society will aid them pass through the adolescent stage with confidence. Adolescents who are of age and want to establish a lasting relationship or feel they can marry after 18years can do that. But they should be prepared for this adventure. Hence the pre-marital preparation should be given by trained marriage counsellors. Pre-Marital Preparation and Counselling Pre-marital preparation and counselling provide an opportunity for a would-be couple (adolescent couple) to begin a type of communication that helps them understand life. The adolescent couple can learn to discuss their different expectations and roles and decide on areas of responsibility. The pre-marital preparation and counselling also help the adolescent couple to deliberately and mutually develop rules to guide their behaviour and address their weaknesses. This means the would-be adolescent couple should operate in ways which mutually assist each other in their impending marriage. Almost all religions demand that the would-be couple should live exemplary committed lives commensurate to accepted principles and societal norms. Therefore, each of the adolescent partners will bring to the proposed marriage, relationship needs, concerns, personality patterns and resources, expectations and hopes. During their interactions, they develop sound marriage relationships which bring lasting acceptable results. 103 Deep feelings are experienced by the would-be couple who court, fall in love and marry. As time goes on, however, they learn that love has a deeper and more practical dimension than the romantic aspect. Pre-marital preparation is a first step in the marriage process but is non-existent in some of our institutions and the churches/religious organizations in the country. The pre-marital preparation should be given to the adolescent youth as single people who should be exposed to many realities of life. It is during pre-marital preparations and counselling that these basic facts are laid bare and explained to would be adolescent couples who are helped to understand fully what marriage really entails. For several reasons including uncertainties, misunderstanding and miseries, the would-be couple is assisted to prepare fully for marriage and avoid hardship, confusion and destruction. What then is Pre-Marital Counselling? Definition- It is the process of helping two young people anticipating and coping with the many problems that arise in courtship, friendship and marriage. Pre-marital counselling can also be defined as that relationship between a counsellor and two people who are considering marriage, through which assistance is given to the prospective mates to gain a better understanding of themselves, of each other and of what marriage relationship entails. o Does pre-marital counselling improve the marriage relationship? o Does it reduce the incidence of disintegration and divorce or separation? The answer is ‘Yes’ because it prevents later difficulties and contribute to the building of more stable and lasting marriage. Pre-Marital Preparation Counselling Serves Some Useful Purposes o It helps individuals, couple and groups of adolescent couples to prepare for, choose partners and build a happy fulfilling, Christ-honouring or religion honouring and successful marriages. o It helps to work on tolerance, understanding, weaknesses and compatibility for the task ahead (marriage). 104 Pre-marital preparation therefore comes off when individuals are contemplating marriage and need to be educated on marriage. Knowledge is imparted to young people in the form of seminars, workshops, retreats, talks, and lecture after which they are able or find it easier to made more sound judgments, meaningful decisions and best choices of future partners. In this preparation focus is upon:o Knowing and understanding individuals o Identifying and knowing one’s strengths and weaknesses o Up-dating the values untapped and o Identifying and coping with needs to be fulfilled in marriage o Learning about the opposite sex o Roles are discussed o Society’s expectations are examined and discussed. Who are prepared for Marriage? The youth from 17years onwards can attend marriage preparation seminars, talks and lectures. If the youth are taken through this preparation as single people, they are exposed to many realities and find it easier to make more sound judgment, good decisions and best choices among a lot of options. Pre-Marital Counselling The basic aim of pre-marital counselling is to help the prospective mates to acquire information on marriage, understand who they are, why others are different, plan and make useful decision and implement their decisions about their life together with precision. Spiritually marriage in the church or Moslem way is a service to the Almighty God and it is regulated by His commandments. It is an affirmation that God joins two people together and the congregation members give approval and support to the union. Different people marry for various reasons—some are negative, others are purely positive reasons. One must however, recognize the weaknesses inherent in marriages which are based on negative motives. Prior to the marriage, young people must be shown the value of sensitive, honest communication. They must be encouraged to discuss their feelings, expectations, 105 differences, attitudes and personal hurts. They can learn to communicate about all issues and to listen carefully as they try to understand each other and talk through concerns without hiding any feelings. Pre-Marital Counselling is meant for: o People who have received pre-marital preparation and have consequently made a choice of a future partner o Adolescent couples who have inadvertently made the choice already but have not been prepared formally o Mature male or female adolescent intending to marry The following categories of people should not be given pre-marital counselling: o An abnormal and retarded person o Couples who have a week or two to celebrate their marriage o Couples who have demonstrated openly that they are marrying for negative reasons o Pregnant girls intending to marry—they need lessons rather on parenting. In the Ghanaian culture when a girl is pregnant, parents do not receive knocking drinks or dowry from the man who impregnated her. Reasons are that child may or may not live; the child may turn out to be that of another man, after birth, if it is stillborn, and the couple may not be interested in marrying each other. In view of the above, a pregnant girl may be so pre-occupied with herself and her condition that she may not be able to make good judgments and decision during the counselling. Topics to be considered during Pre-Marital Counselling It is difficult to identify certain problem areas as being unique to pre-marital counselling because of individual differences, values and needs. The following topics are suggested with the hope that would be couples especially the adolescents will have ample time and opportunity to share their thoughts and deliberate on some of the topics. For the adolescent couple in depth information giving is necessary. 106 Suggested List of Topics - Friendship, Courtship and Marriage - Motives for Marriage—Positive or Negative - Love - Maturity or Marriage—Emotional, Social, Educational - Marriage—Definition, Biblical, Koranic and Legal Foundations or other - Individual Differences Between Males and Females - Understanding Roles in Marriage - Friends in Marriage - Home Management - Finances in Marriage - Creative Child-Upbringing - Sexual Intercourse - Adjustments in Marriage - Communication Before and After Marriage - Religion - Self Disclosure - In-Laws - Vocation and Career - Separation or Divorce Pre-marital preparation and counselling can spread over a year for thorough preparation and between 3 and 6 months for counselling and education. 107 In conclusion, premarital counselling seeks to prevent marital problems/concerns and personal conflicts that could make life difficult and unbearable. Adolescents by observing parents and older adults learn what to expect in marriage, what they want and what they do no want. It is therefore necessary to offer the needed help, counselling and education to those who need it and show that pre-marital preparation and counselling can really help assist the young person (adolescent). The adolescent can learn to anticipate difficulties in marriage and family living, teaching them how to communicate and resolve problems effectively are very essential and helpful. A healthy marriage relationship can help couples (adolescents) to build a lasting mutually need, satisfying and more growth nurturing. Marital Counselling for Young people Marriage is not a very stable institution in many countries of the world today. Some marriages are happy and interesting while others are not. Many spouses are not committed to their marriages. Some couples, even believers have resorted to divorce and separation as a way of escape when marital conflicts, troubles get too hot and difficult to handle stress form within and outside have also put a lot of pressure on modern marriages for old and new marriages. It is not easy to assist couples to resolve marital conflict and build better and stable marriages, but this can be one of the most rewarding of all counselling experiences and challenges. Counselling Couples Counselling couples before marriage had been dealt with earlier to establish a successful marriage. Topics treated cover all aspects and married life, which if handled properly would satisfy both husband and wife (Refer to suggested topics treated in pre-marital counselling). Counselling one person is a difficult task. Counselling a husband and wife (couples) is even more difficult and requires special skills and alertness in the counsellor. The counsellor should expect skepticism about the services he/she offer. Some spouses also 108 resist, are hostile, and may even cause physical damage to counsellor and the other client. Counsellor should therefore look at him/herself before he/she starts (and frequently thereafter) to clarify some of their own attitudes, prejudices, motivation and vulnerability. Counselling goals -Identify and understand specific issues -Teach the couple how to communicate constructively - Teach problem-solving and decision making techniques - Help them to express their frustrations, disappointments and desires - Keep husband and wife together - Insist hope - Teach the couple how to build a marriage based on biblical and other religious principles as may apply Since people vary, there is a no step-by-step recipe that can work for all marital counselling. Just make sure you focus on the couple, the problem and some processes in counselling. Focus on the Clients (Couple) Seek to understand the couple, their feelings, and their frustrations as well as understand the problem. The basic qualities of empathy, genuineness and warmth are very crucial in marriage counselling. 109 Focus on the Partner who Sought Counselling o Try to be supportive o Slowly move counselling toward solving the problem o Guide them to change attitude, behaviour, confess and re-examine their perceptions on marriage. Focus on Processes – ask these questions How does the couple communicate? Do they criticize each other? Does one partner dominate the other? Does one or both of them withdraw when there are disagreements? Do they attack each other’s integrity? Carefully watch the couple as they interact with you. At the end, review what the couple has learned with them. Point out to them the need to grow personally, interpersonally and spiritually. Asses the Marriage E.g. why has the Couple come for help? - Gently probe for more details and try to raise questions that will give more information and a better understanding of the problem. -Get the couple to describe specific incidence of conflict -Watch out for feelings of rejection, anger, hurt, frustration and fractured self-esteem. It is important to accept the fact that you and your spouse have difference. Sometimes you wish you could change things you don’t like in your partner. Don’t be too quick to find fault with your spouse. 110 It takes time and patience to effect change. Go about changes gradually, tactfully and lovingly and the two of you will enjoy and appreciate them. A good marriage is not one where perfection reigns; it is a relationship where a healthy perspective overlooks a host of unresolvables. Perfect spouses/partners don’t exist. You have to work at your marriage. You need to adapt to or accept the weaknesses and loopholes that you cannot change. Think of how to make your marriage work. Adolescent couples can benefit immensely in counselling, effective counselling can change your marriage. Start marital counselling now. 111 112 CHAPTER SEVEN: COUNSELLING ADOLESCENTS AS PARENTS INTRODUCTION: Many adult men and women want to become parents when they are ready and can pay for it. However, when pregnancy is unplanned, adults and adolescents often face difficult decisions. When an adolescent chooses to have a baby and become a parent, this might be done with a partner, spouse, parents, grandparents and other family members or on their own. Often adolescents do not understand the long term consequences of having a child. Usually, adolescents are unaware of the commitments involved. Raising babies at any age and the family structure is challenging no matter what. It is important to stress to young people that even with the help of others, being a parent is not easy. Parenting is often complicated and frustrating. This is because a child’s needs will constantly change and so will the parents ability to meet them. A child will look to his/her parents for love and care all day and everyday. It takes years for children to become responsible for themselves. Convenient and affordable childcare is often difficult to find. Families, teachers, health workers, the media and communities should share some pertinent information with young people regarding adolescent parenting. The information should include the following: o Adolescents are at a much higher risk than older women of suffering serious medical complications during pregnancy. These complications include anaemia, pregnancy losses, difficult labour, premature delivery, cervical trauma and other birth injuries. o It costs a lot of resources especially money to raise a child, these resources most young people do not have especially in our part of the world. o Many adolescent mothers do not complete school or their vocation training and this makes their financial status low if help is not obtained. 113 o Adolescent parents become more dependent on their own families and friends for emotional, physical and financial support for them and their children. This situation puts them at a second rate level in some circumstances. o Adolescent parents have to give up a lot of freedom to be good parents. o Parenting requires lots of love and unlimited energy and patience. o Having a child is not surely for maintaining relationships in adolescence o A child needs to be taught the do’s and don’ts of his/her culture with love and firmness o Parenting skills are learned so they need to be willing to access information and experience from all sources available e.g. books, other parents etc. Young people, families and communities need to be patient and accessible when unplanned pregnancy occurs. There is need to involve pregnant adolescents and their partners in decision making to allow for informed choice on what to do about the pregnancy. Pregnant adolescents need support and guidance based on their rights and responsibilities when pregnancy occurs. Adolescent parenting without a partner may be challenging but exciting and rewarding if done well. It is easier to find support that is available. It is a good idea for single adolescent parents to let family and friends know their support is needed before deciding to parent. Many times the decision to parent is not made by the adolescent but by parents/guardians. When this is the case parents/guardians need to understand that the adolescent parent will need lots of teaching and help to be a good parent. They can model good parenting skills for the adolescents as they continue to parent him/her. It is important that their anger and disappointment in their adolescent child/does not result in rejection, neglect or abuse of either or both the adolescent and the baby. This can lead to the adolescent doing likewise to the baby and thus perpetuating a continuum of rejection, neglect and abuse. An adolescent whose sexual partner has rejected her may reject the child when he/she is born. Poverty and other difficult circumstances may also result in the rejection of the baby. When this happens the adolescent will need help to grow to accept and love the child. If the adolescent continues to resent his/her baby, it would be better to foster the child or have him/her adopted. 114 Adoption either by a relative, parents or an outside family need to be discussed with the adolescent if this is a possibility. If an adolescent had to give up his/her child, he/she will need counselling to help them cope with the loss. Some General Parenting Tips Most parents love their children dearly and want the best for them. However, parenting children is not easy and often makes parents frustrated and helpless. It is important to remember that no one is a perfect parent. We learn to become parents and mistakes are inevitable. There are some principles, however, that can help us parent more effectively. Loving your children and letting them know it Many parents assume that their children know they love them. After all they provide for their needs to the best of their ability. However, this is not the case. If you do not show to your children through your behaviour that they are loved, they will not know or feel it. How to make your child feel loved 1. Touch them often, for example, rub their backs or head affectionately, hug, kiss, etc. 2. Tell them you love them often. 3. Praise them when they do something well and give them opportunities to do things so you can praise them often. Be specific in your praise. For example “You did well to wash the dishes without being asked. Thank you” instead of “you are a good girl”. 4. Listen to them and encourage them to express their thoughts, feelings and needs. 5. Talk to them often. 6. Play with them often. 7. Spend free time with them, go to football matches, shopping, walks, etc Discipline your child: Discipline involves ―training a child in the way he/she should go‖. Many parents seem to think that discipline means punishment. Discipline may involve punishment at times, but there is more to it than that. Disciplining a child is much easier when the child feels loved and cared for. 115 Discipline with no love only produces rebellion and emotional problems. Letting children do whatever they want on the other hand produces spoiled and demanding children. How to Discipline: 1. Instruct and show children how to behave properly. 2. Request for appropriate behaviour, instead of using commands. For example, “Could you please make your bed before going out to play?” Instead of “You are not setting your foot out until you make your bed.” 3. Use forceful commands only when necessary and not routinely. 4. Children copy their parents. Be a good example for your children. 5. Parents should agree on how and when to discipline. 6. Use punishment only when a child has broken a major rule. 7. When punishing a child, let the child know why he/she is being punished and what the correct behaviour should have been. 8. The extent of punishment should depend on the severity of the wrongdoing. Parents should be just. Do not let your anger determine the severity of the punishment. 9. Reduce punishment when a child shows he/she is sorry. 10. Let the child know you love him/her despite the need for punishment. 11. Let discipline be consistent. Keep giving the correct instruction. Do not overlook wrongdoing at times and correct it at other times. However, be flexible with rules when the situation demands it. For example, when a child oversleeps because they woke up in the night to fetch water. 12. Do not transfer anger from other sources unto children. For example by yelling at your child because you are upset about not having any food in the house. 13. Effective ways of punishing include denying the child of a pleasure (not a need), for example not being able to play football one afternoon; limiting the child’s freedom etc. 14. Ineffective ways of punishing include bodily pain, insults and ridicule. 15. Spanking is not effective for children under the age of two. They do no understand and just get frightened and confused. After age five spanking can also breed resentment and rebellion. 16. Remember it is more effective to praise and encourage children for what they do right than to wait for misconduct. Not doing anything wrong is also a success so praise children for that as well. This is especially helpful for children who do many right things that can be praised. 116 Dealing with boredom and encouraging creativity Children who have nothing to do and are bored may get irritable and get into trouble to create some fun. Parents need to help children find creative and positive things to do. Joint problem solving can be used either with your own children or a group of children in the area to find creative things to do. Encourage children to relate to other children and to think up new ways of spending time. Adolescent parenting with a partner enables responsibility, difficulties and pleasures to be shared. Usually, a closer relationship is developed between partners and can lead to the reality of becoming parents. A child can bring joy, stability and other rewards in the relationship. This is a good opportunity for being deeply 117 committed whether married or not. CHAPTER EIGHT: CAREER COUNSELING 8.1 INTRODUCTION: Career choice is a major decision for young people. The process of making a career choice starts during mid to late adolescence and reaches a peak during young adulthood. As such, it is important that adolescents get some help in making such decisions. For adolescents in school it is expected that they would get some of such help in school. Unfortunately most schools apart from giving sedimentary help in the choice of Senior Secondary School (SSS) subjects especially the electives give no help to the Junior Secondary School (JSS) students in thinking through career choices which would become the basis for the course selection in SSS. This deficiency is also evident at the senior secondary school level. A few schools invite staff or counsellors form the university to talk about grade and course requirements for various courses at the university level. However, there is little effort at informing or introducing the student to the world of work and helping them decide which particular niche they would fit in practically and emotionally. For most people then, the career choice is often haphazard. They start off as young children imagining what they would like to be when they grow up. Most of what they imagine comes from the world around them with no realistic plans as to how or whether it is possible to realize these dreams. During adolescence thoughts of possible careers become more realistic as they adolescents realise that there are limits and barriers to some careers whilst others are more accessible. Many young people then drift into courses that peers may be doing or what is fashionable at the time without making a clear decision. For example, students who do biology as an elective start thinking about medicine as a career because peers are doing so and ―all good biology students do medicine‖. Often no individual evaluation of what the career actually consists of and whether one is emotionally suited for it is carried out. Thus there are many factors that influence eventual career choice e.g. socio-economic status, family background, school attended and school achievement, gender, intelligence and personal 118 interests. Young people need guidance to start through all of these factors to arrive at informed and realistic choices. 8.2 COUNSELLING FOR CAREER CHOICE There are very few professional vocational counsellors in Ghana. Therefore, all adults who work with adolescents need to have some idea of what goes into a realistic but satisfying career choice and be able to help adolescents in making such choices. Often they may be the only knowledgeable adult the adolescent could consult. As such it is important that such adults know how to help in making career choices. Giving help in career choice involves helping young people: Become knowledgeable about the work world. For example work ethics, various occupations, what the jobs actually entail, what qualifications are needed for fist job entry, whether they train on the job or not, what are opportunities for advancement etc. Become aware of their own interests, aspirations and goals as well as their aptitudes, dispositions and suitability for particular jobs. Make realistic plans to meet training requirements and gain skill in applying and interviewing for jobs. Deal with any anxieties, fears and self esteem problems that may affect realistic assessment of one’s abilities. The biggest challenge that career counsellors face is the lack of information on job opportunities in Ghana. There are limits to the information that a young person can access to make the required decisions. This is an area that the Ministry in charge of Manpower needs to tackle urgently. Once such information is available schools could access them for career centres in their schools. Such centres could also house the various qualifications for university, polytechnic, etc. as well as the training requirements for various jobs. Opportunities for observing various jobs or even work during the holidays could be organised by various schools and would be very helpful for school youth in making career decisions. 119 As of now even professional Ghanaian counsellors do no use psychological tests to assess interests, aptitudes, etc because of validity and reliability issues and problems of testing process. As such interviews, self assessment and assessment by peers, teachers, parents/guardians and any significant others become very important in arriving at vocational decisions. Career Choice for Out-of-School Youth The above process concerning career choice is as valid for out of school youth as they are for in school youth. Since career centres do not exist, concerned adults need to gain the know-how to help such youth access the job market with the same processes outlined above. Out of school youth may need information about apprenticeships, opportunities for vocational training or going back to school. There may be jobs that offer in-house training that they could access. The importance of information as stated earlier cannot be over emphasized. However, in addition to this, out of school youth often need help with emotional and motivational issues to help them overcome the barrier of inadequate schooling to reach their potential. Assessment of potential should be sensitive and creative in order to reveal inherent aptitudes that have not been tapped. Information on existing livelihood skills programmes for the out-of-school youth should be shared. 120 CHAPTER NINE: PLANNING FOR YOUR FUTURE-WHAT YOUNG PEOPLE NEED TO CONSIDER 9.1 INTRODUCTION: Planning for the future is about keeping doors open for you. That means keeping lots of options available. Believe it or not, decisions you make today can really change the options you have available to you in the future. In this write up, the writer seizes the opportunity to share with ‘colleague’ young people and adults what benefits accrues when young people start planning for the future very early in life. In fact the popular saying that “if you fail to plan, then you plan to fail” must be a guiding principle. I will consider the topic under the following areas of consideration: • Education • Support to others • Health • Professional • Finances • Employment • Career Options • Friends • Family • Connections • Retirement • Religion • Entertainment • Have a Dream 9.2 Education Education, to my mind is the most important asset any human being should endeavour. The Bible says in Hosea 4:9 ‘My people are destroyed for lack of knowledge’. Yes without education, one perishes and becomes limited in all that he/she does. Formal and informal education are key. Education opens the doors for ‘slaves’ to dine with kings! and ensures that challenges turn into opportunities. Young persons must aim to be educated and pursue the agenda with great determination and zeal. Every aspect and level of education is important. Formal and informal education must be taken 121 very seriously. Parents should be open to teach and learn from their kids. To the young person, once you get to 16 years of age, you have got some decisions to make about your future: Which route should you follow? There are different ways of gaining further qualifications, skills or work experience. You could: - continue in full-time education, either at school or college/tertiary - continue your learning through work-based training. It pays to keep learning Aim at the highest level of education possible (within your means) Remain focused and save towards this Routes into university and higher education Ghana’s educational system starts with basic education which includes nursery, kindergarten, primary and junior high school, through senior high school and then tertiary education either at the Polytechnic or the University or any of the training colleges By continuing with full-time learning or starting an Apprenticeship, you can take important steps towards qualifying for a higher education course. Higher education can open up new career options, and there are more ways to get into college or university than ever before. 9.3 Health The ancient Greeks have a saying which is translated as “A Healthy Mind is to be found in a Healthy Body”. Remaining healthy is a choice and not by chance. Health is defined as a STATE of complete mental, Physical and social well being of an individual and not merely the absence of disease or infirmities. A fulfilling future is embedded in good health in the future. Frequent ill health will erode your confidence and jeopardize your future! 122 What life style you lead now could affect your future health. Use of alcohol, smoking and lack of exercise could lead to cirrhosis of the liver, lung diseases including cancers of the lungs and throat and worsen diabetes and hypertension which can reduce your life span. How regular to seek medical advice can play important part in your future health. Learn to put aside resources to enquire about your state of health. Invest in your health for it is the only asset you have that when lost cannot be replaced. What Insurance options you choose is important. Look for the best. The National Health Insurance Scheme is a must join option. The private schemes may offer more options at a higher cost. Just invest in your health! Read about common diseases. Knowledge is power. Knowing about malaria, tuberculosis, diarrhoeal diseases, common cold, diabetes, hypertension and asthma among others could help you understand them and deal with them if afflicted. Being ignorant could hasten your race to the grave! Remember regular routine medical check ups after age 40 yrs is mandatory. Work this out with your Physician and try to comply at all times. 9.4 Finances Your finances must be planned and executed well. Budget and stay within budget. Avoid ad hoc expenditure. Invest wisely and ‘grow’ your money because when ‘planted’ money ‘grows’. Remember the keys below will be a helpful guide: Live within your means- do not compare yourself with your neighbours and live like them. They may be earning far above your income. Be yourself and spend wisely. Plan and save towards your goals- education must take priority over all others. Parents must invest their monies in their kids’ education. Young people must invest their time LEARNING!!!!! Invest in business opportunities- be bold and take risks. No businessman thrives without taking risks. Seek professional advice and invest. Opportunities lost may be lost forever. Diversify if you have opportunity- do not only remain an engineer, a doctor, a teacher or a banker etc. Learn to invest in other areas because money can flow from all directions. You may want to engage a financial consultant- paying a professional to help you invest is a wise thing. Grab the opportunity and seek counsel. 123 Financial discipline- as stated earlier, be financially disciplined and do not spend ‘by heart’. Live within your budget 9.5 Career Options What career you choose will largely determine your future happiness and joy. This will also be affected by the type of education you get. So whilst in school seek guidance and counsel from other professionals, your parents and relations to identify your strengths and weaknesses to enable you pursue a career. Considering the following is crucial: What type of career would suit you? A good way to start your planning is to think about what motivates you as a person. Make a list of activities you have enjoyed - both inside and outside school, college or work. What was it about them you liked? There are no right or wrong answers – but, for example, you might find that you enjoyed: - getting to know more about a particular subject - solving challenging problems - working as part of a team - meeting new people Once you have got a clear idea of your interests, the next step is to start looking for a career that matches up with them It is never too early to start thinking about careers. Be on the look out for fairs and events – especially those that focus on a career you are considering and attend with the mind of learning more about it. Remember that you will get more out of them if you go prepared. A careers adviser will be able to give you some tips on how to prepare. If you are doing a course and planning to get a job when you have finished, start preparing well in advance. Make sure you ask the permission of the person you are going to put down as a referee. Find advice on job applications and how to put together a curriculum vitae (CV) 124 It is worth thinking about a ‘plan B’ in case you do not get your ideal job at the first attempt. Would further study improve your chances? How about doing something in your spare time related to the career you want? More things to consider: Once you have got a good idea of where you want to go with your career, there are a number of other things you will need to consider - like pay, location and the job market. Be prepared to work anywhere in the country but consider areas where the opportunity for career growth and children education is highest. When you are ready to look for a job, it’s also worth thinking about what type of work would suit you. Will you be looking for flexible arrangements to help you fit in study or childcare? Or do you like the idea of working for yourself? Ask yourself the following question and try to answer them as part of the effort to settle properly in a good career! What do you see yourself doing ten years from now? 2. List 3 jobs you might see for yourself? 3. If you’ve got a particular career in mind, it’s also worth finding out if you need to have specific qualifications, skills or experience 4. Once you've decided the career you want to get into, you can start planning how to get there. There's a lot to think about, so the earlier you start the better 5. Developing your skills throughout your working life will give you the best chance of getting the career you want 6. Do you think you want to work indoors or outdoors? 7. Do you like working with your hands? 8. What special talents or abilities would you like to be able to use in your career? 9. Do you like working with people or alone? 10. Are there activities you really want to avoid (like writing, reading, etc.)? 11. Might you want to live in a foreign country? 125 Listen to people who know you best Once you are armed with expert advice, it can be useful to get advice from the people who know you best, but they won’t always know a lot about the career you are interested in. Remember – it is your career. You know what you are good at and you know what you want to do. Do not be put off if your dream career means taking a different direction from friends and family. Teachers and lecturers will have a good idea of what you can do with the subjects you are studying. But they only see what you are like at school or college, and this might not be the whole story. - For example, you may be quiet in the classroom but spend your spare time producing materials for broadcast or working on hospital radio. If this is the case, there is nothing to stop you pursing a career in radio. - It is worth getting advice from other sources as well The point is, in the big picture, no one is going to look after your career for you, but you. 9.6 Employment Employment is key to your future happiness and progress. Good employment correlates positively with good education. The higher you go, the better it becomes. Indeed opportunities are brighter with people with higher education. I will recommend the following: Aim to be self employed (be bold). Many successful people started private business when they had nothing. Have the right competencies. Be accountable to yourself and employers/employees as well as your colleagues. Honesty pays. Be prepared to learn from your superiors and subordinates. Everyone has something to share with you. Mentor others and be prepared to be mentored by others Serve and do not expect to be served 126 9.7 Family Family links are crucial for the future direction. A family that believes in education may go all length to support its members to have the best education. The determination of parents to see their children educated has led to many ‘well educated’ individuals in the society. Keep to the family ties because some members of the external family may be the only conduit for ones educational prowess. When you are ready to marry, do that out of love for each other rather than material considerations. Plan your family and have the right number of children. The principle to guide you is enshrined in the following: Have strong family links Help other members of the family if you have the means Plan your own family with your spouse. Have children by choice and not by chance Have children by choice and not by chance Guide the children with right mental attitude Be an example to others both in and outside your family. 9.8 Retirement Planning for your retirement should begin with the very day you are employed. Set yourself goals and follow the milestones. Be determined to execute your retirement plan because many have retired in great surprise. Strategic investment may be crucial. Some suggestions for your consideration: Plan your retirement and save towards it. Be innovative and consult those who can help you achieve your dream. Food, clothing and shelter must be targeted in old age. Some have retired and died prematurely because they had no dwelling place. Join SSNIT and similar schemes (even if self employed). You may add to this with other innovative approaches Invest in your kids especially their education- your most meaningful investment Strategic investment may include farms, buildings, booming business etc. Learn also to diversify. 127 9.9 Entertainment ‘All work and no play, makes Jack a dull boy’. You will recall this as an adage but in fact learn to have fun and be entertained. It improves health and emotions. Make conscious effort to invest in entertaining yourself and the family. Keep it safe and clean; avoid ‘dangerous’ entertainments!!! The principles to keep are: Have good entertainment package for your self and family on regular basis Travel and tours- visit tourist sites in and out of Ghana. Aim to take your family along because frequent travels underpins maturity. Ensure a happy family-let your kids and spouse be your best friends 9.10 Support to others Have joy helping others progress. Provide direct support or support through associations and groups like Rotary club, Church groups, etc. Aim at helping needy family members and enhance their opportunities on earth. Apply the following if you can: Bless and be blessed Invest in others who share similar ideas (investment not only in cash) 9.11 Professional Aim to be a professional. Remember career options include professional goals. Be ambitious but do not be anxious. You are a ‘great’ Professional if you: Join professional associations Let the community benefit from your professional knowledge Aim high professionally ‘Opportunity comes but once’. Learn to take every good opportunity that comes your way and make good use of it. 128 9.12 Friends ‘Show me your friend and I will show you your character’ is a very popular adage. It is true that friends influence either positively or negatively. Be sure to: Choose your friends and do not let them choose you Relate well with your friends-it is crucial for healthy friendship Know what and when to discuss issues with friends. Be sensitive to their emotions. Align your vision to the type of friends you make 9.13 Connections Remaining connected keeps you in contact with the larger world. People might be in a better position to recommend you for success. Ensure that you relate well with all persons you interact with. Keep the following in mind: Remain in contact with all people who have been helpful Do not break links with good school friends- you might need them The people you meet and interact with in life are the ones that prop you up 9.14 Religion You may have your choice. Whatever choice you have, try to keep to the religious principles enshrined in your religion. Most people on earth are religious and I guess you are too. Therefore: Just be religious: Because self discipline and prosperity are synonymous with good religion- at least I know this for Christianity, Islam, etc. 129 9.15 Have a Dream ‘…I have a dream that my four little children will one day live in a nation where they will not be judged by the colour of their skin but by the content of their character. I have a dream today’. This is a popular phrase in a speech delivered by Rev Martin Luther King Jr of the USA as he stood on the steps of the Lincoln Memorial in Washington, D.C on 28th August, 1963. Today his dream is materialised and Barack Obama is the first African American to be the Presidential Candidate of a major Political party in the US. He could be the President in a couple of weeks!!! ‘Never say never’. Have a ‘can do’ attitude. Let me leave you with the following principles: HAVE A VISION: Being visionless is worse than blindness-you see with your mind but you look with your eyes Dream big- you can never be arrested for dreaming Remain focused in order to attain your dreams Self discipline will help you reach your vision Refuse to be distracted- it is your dream not that of others Success begins with a defined destination. You cannot reach anywhere when you have no destination in mind!!!! YOU ARE THE MOST IMPORTANT ELEMENT IN THE EQUATION: DEVELOP YOURSELF and PLAN YOUR SUCCESS. After all ‘where there is no VISION, the people perish, but he who keeps the law, he is blessed’ Proverbs 29:18 130 APPENDIX A Scenarios for Counselling Practice A seventeen year old adolescent with one child comes to the clinic. She wants Norplant implants to be inserted for her. She wants to further her education (FP) A sixteen year old adolescent who has had an abortion comes to the clinic and wants a contraceptive method (FP). Adjoa, an eighteen year old JSS student is three months pregnant. She is being pressured by her sugar daddy to go in for am abortion. Adjoa comes to the counselling centre for help. Mary is nineteen years old and is one month pregnant. She wants to continue her education to the university level. She comes to the clinic for information on services for abortion. (Safe Abortion). Kwame has got gonorrhoea. He has a regular girlfriend Ama, but he occasionally has sex with Susie who has a sugar daddy. He had sex with both of them in the week before he started having symptoms. (STIs). A nineteen year old boy Kwesi comes to the clinic with a complaint of condom breakage during ejaculation. He things his girl friend Joyce might get pregnant. (ECP). Kwesi comes to ask for help because his mates have been teasing him for having a small penis and he is planning to leave school. Araba, came to see the counsellor because her boyfriend wanted to have sex with her against her will on one of their outings. She is really upset. Yaw is fifteen years old, he has been having wet dreams for some time. He is worried, withdrawn and embarrassed. He does not know what to do. Johnnie has listened to a talk on AIDS and he is afraid. He is eighteen years old and has had sex with three girls in his life. He also heard from a nurse that you could get HIV with just one round of sex with one girl. A person can have HIV in the body for years without any sings. One of his former girlfriends has been loosing weight of late. He thinks he has got the infection (HIV). 131 Kwame comes to you complaining of painful urination and discharge from his penis. He is very angry with his girlfriend who he says has given him the infection and comes to you for help. (STIs) Kofi’s mother comes to ask for help because Kofi has been putting up some funny behaviours and she thinks her son is on drugs. In fact she caught him smoking cigarettes on two occasions. She is afraid that things may get out of hand. (Drug Abuse). A woman comes to the clinic/centre worried that her fourteen year old daughter was raped that day. She is afraid that her daughter might get pregnant. (ECP). Kwame has been flirting with two adolescent beauties. He seems to love them both. He is an only child and a middle aged trader. Both girls got pregnant around the same time. His mother advices to abort one of the pregnancies. He is so scared. He comes to you for help. (Safe Abortion and Care for Adolescent Pregnancy) Ama has a fifteen year daughter who is very difficult at home. She is threatening to leave school and Ama is worried (School Dropout). Aku, an SS2 adolescent lists contraceptives in her list of requirements to a boarding school. Her mother notices this and goes to a counsellor to complain for help (Contraception). Kofi asked permission twice to take his girlfriend to “Joyful Ways” evening concert. Now the girl is pregnant and Kofi has asked his father to see the girls’ parents on his behalf. Counsel Kofi and his father (Adolescent Pregnancy). Mary has been married for the past ten years without an issue. Suddenly her husband introduces a sixteen year old girl as his daughter, who is now going to live with them in the house. She is very devout but has not been able to sleep since the girl Afua was brought. She comes to you for counselling (Managing a Step Child). An adolescent has a girlfriend he wishes to marry. He had several sexual partners before he met Kukua. However, the fiancée knows about them. She herself is a virgin and had heard about AIDS. She comes to you worried about her fiancée’s past and asks for counselling. (HIV Information Counselling and Testing). 132 Esi, an adolescent mother has a two year old son whose father she does not know. He just started walking and does not look very healthy. She is contemplating abandoning him by the river. Help her save a life (Managing an Unwanted Child). A sixteen year old adolescent is under achieving at school and does not get on well with his parents at home. He is unhappy at school and at home. The teacher sends him to see the counsellor. (Parent-Adolescent Relationship) 133 134 APPENDIX B Pre-marital Information Sheet PART 1 BACKGROUND 1. Name:…………………………………Nickname:……………………………….. 2. Age…………Birthday………………..Place of Birth…………………………….. 3. Do you have any sisters and brothers?..................................................................... 4. Any Previous Marriage?............................................................................................ 5. Number of Children and ages……………Name of other parent…..……………… 6. Your obligations/responsibilities to the children?..................................................... 7a. Have you ever smoked?....................Yes…………………. No…………………… 7b. Comments……………………………………………………………………………. 8a. Have you ever used hard drugs?.....................Yes…………………. No………… 8b. Comments…………………………………………………………..……………. ………………………………………………………………………………….……. 135 9. Comments………………………………………………………………………… …………………………………………………………………………………......... 10a. Have you ever had sexual intercourse? Yes…………………No………………. 10b. Comments?............................................................................................................. 11a. Have you ever had sexual intercourse with your partner? Yes……No……. 11b. Comments?..................................................................................................................... PART II 1.What is marriage?....................................................................................................... ………………………………………………………………………………………… 2. Reasons why you want to marry?............................................................................... ……………………………………………………………….…………………………. 136 3. Three aspects of your parent’s marriage you will like to emulate: a)……………………………………………………………………………………… b)……………………………………………………………………………………… c)……………………………………………………………………………………… 4) Why do you want to person?..................................................................... marry him/her and no other ………………………………………………………………………………………… 5) What does the Bible say about marriage? …………………………………………………………...... ………………………………………………………………………………………… 6) Which type of marriage do you want to contract (customary, Ordinance Islamic)…………………………………………………………………………………………………………………………………… or 7) How many siblings of your parents are married?.........................................................................................…………………………………………………………… …………………………………………………… 137 PART III 1. List five qualities that You have He/She You expect from your spouse a. b. c. d. e. 2. List five (5) things you like about yourself a………………………………………………………………………………………… b………………………………………………………………………………………… c………………………………………………………………………………………… d………………………………………………………………………………………… e………………………………………………………………………………………… 3. List five (5) things you like about your adolescent partner? a………………………………………………………………………………………… b………………………………………………………………………………………… 138 c………………………………………………………………………………………… d………………………………………………………………………………………… e……………………………………………………………………………………....... 4. List five (5) things you dislike about yourself a………………………………………………………………………………………… b………………………………………………………………………………………… c………………………………………………………………………………………… d………………………………………………………………………………………… e………………………………………………………………………………………… 5. List five (5) things you dislike about your partner? a………………………………………………………………………………………… b………………………………………………………………………………………… c………………………………………………………………………………………… d………………………………………………………………………………………… 139 e………………………………………………………………………………………… 6. If you could change two (2) things about yourself, what would you change? a………………………………………………………………………………………… b………………………………………………………………………………………… 7. How do you plan to make yourself a better person? ………………………………………………………………………………………… ………………………………………………………………………………………… 8. How do you plan to make your partner a better person? ………………………………………………………………………………………… ………………………………………………………………………………………… 9. List three (3) spiritual goals that you have a………………………………………………………………………………………… b………………………………………………………………………………………… 140 c………………………………………………………………………………………… 10. List three spiritual goals you have for your family a………………………………………………………………………………………… b………………………………………………………………………………………… c………………………………………………………………………………………… 11. Why are you interested in pre-marital counselling?..............................................................................……………………………………………………… ……………………… 12. Why do you come to me service?............................................................................................ ………………………………………………………………………………………… 141 for this PART V 1. List things you spend money on every month……………………………………………………….. ……………………………………………………………………………………………… ……………………………………………………………………………………………… 2. Are you indebted in any way? Yes/No To whom…………… How much…………………… How long…………………… 3. How do you plan to pay back?........................................................................................ 4. Do you TITHE Yes/No How much and how often……………………. 5. Other responsibilities you have (financial)……………………………………………………………… ………………………………………………………………………………………… 142 PART VI SPIRITUAL—for Christians only 1. Have you accepted Jesus as your Personal Saviour? Yes/No 2a. When and how……………………………………………………………… 2b. Name of Church………………………………………………………………………… 2c. Name of Pastor I Charge……………………………………………………………... 2d. Address………………………………………… Tel……………………………….. 2e. Membership since……………………………………………………………………. 2f. Responsibilities in Church…………………………………………………………… …………………………………………………………………………………………… 3). What role does the Bible play in your life?..................................................................... …………………………………………………………………………………….. ……… 143 APPENDIX C Adolescent Behavioural and Fertility Indicators for Ghana Behavioural Indicators HIV prevalence among pregnant youth 15-24 years 2003---------------------------------------------3% 2004---------------------------------------------2.1% 2005---------------------------------------------1.0% 2006---------------------------------------------2.5% 2007---------------------------------------------2.6% Source: NACP reports Fertility Indicators 1998 2003 Age at first sex: 17.5 years 18.3 years Age at first marriage: 19.1 years 19.6 years Early Births (<20 years) Adolescent contraceptive use 32% 23% 5% 6.9% Source: Ghana Demographic and Health Survey (GDHS) reports 144 REFERENCES 1. National Adolescent Health and Development Training Manual for Healthcare Providers- First Edition, December, 2005 2. ABC of Counselling Adolescents Towards Behaviour Change, First Edition, 2002 3. Programming for Adolescent Health and Development. Report of a WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health 4. WHO discussion Paper on Adolescence. Issues in Adolescent Health and Development, WHO 2004 145
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